A new mother and her baby are to be discharged from the hospital tomorrow. Which behavior indicates a need for further instruction before discharge? The mother:
a. Changes her baby's diaper, then shows the nurse the contents of the diaper
b. Continues to hold and cuddle her baby after she has fed him
c. Leaves the baby on her bed while she takes a shower
d. Reads a book while her baby sleeps
ANS: C
Parent education should provide information on ways to protect a newborn from injury, including never leaving the baby unattended on a changing table or bed because the baby could roll over and fall.
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During an assessment, the nurse asks a female patient, "How many alcoholic drinks do you have a week?" Which answer by the patient would indicate at-risk drinking?
a. "I may have one or two drinks a week." b. "I usually have three or four drinks a week." c. "I'll have a glass or two of wine every now and then." d. "I have seven or eight drinks a week, but I never get drunk."
Which of the following causes can lead to excessive burn edema and shock in a patient with injuries totaling more than 50% -TBSA burn?
a. The heat from the burn leads to immediate vascular wall destruction and extravasation of intravascular fluid. b. A positive interstitial hydrostatic pressure occurs in the dermis leading to burn wound edema. c. Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space. d. Capillary permeability decreases in burned and unburned tissue, leading to hypovolemia.
The nurse is assessing an older adult client with a cardiac dysrhythmia. Which finding would the nurse identify as contributing to this client's dysrhythmia?
A) Drinks caffeinated coffee in the morning and for lunch. B) Does not smoke or ingest any alcohol. C) Plays golf three times a week and gardens daily. D) Takes antihypertensive medication as prescribed.
The nurse is planning care for an older patient with pneumonia and a stage II pressure ulcer. Which nursing diagnosis would have the greatest priority for this patient's care?
1. Acute Pain related to destruction of tissue 2. Knowledge Deficit related to care of skin disorder 3. Risk for Infection related to impaired skin integrity 4. Potential for Infection related to impaired skin integrity