In assessing the eyes of a 4-month-old infant, a nurse shines a penlight in the eyes of the infant and notices that the light reflection is not in the same location in each eye. What is the most appropriate response to this finding?
a. Performing the cover-uncover test
b. Documenting it as an expected finding at this age
c. Documenting that this infant has abnormal function of cranial nerves IV (trochlear) and VI (abducens)
d. Referring the infant to an ophthalmologist
ANS: B
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a. support physician's orders. b. provide direction for all caregivers. c. provide broad, general statements. d. clarify nursing principles.
A client with appendicitis is highly agitated and states that there is a great deal of pain. Which intervention will decrease the client's anxiety?
A) Assess pain levels every 2 hours and administer ordered medication. B) Provide reading material to help distract the client. C) Distract the client with ambulation. D) Administer pain medications when the client complains of pain.
The patient who was recently diagnosed with cancer tells the nurse that she is so grateful for her children and family, because she does not know what she would do without them. Your patient is exhibiting which of the following coping responses?
1. Internal family 2. External family 3. Family communication 4. Social support
Clients with IBS may be prescribed what type of medication prior to meals to prevent diarrhea?
a. bulk forming c. antidiarrheal b. antispasmodic d. antihistamine