A client is admitted with injuries sustained from a domestic dispute. When planning care, the nurse will include which priority assessment?
1. Self-development.
2. Self-esteem.
3. Immediacy of danger.
4. Ability to provide payment.
Correct Answer: 3
The priority assessment for a client who is being abused is to determine the immediacy of danger. Assessing self-development and self-esteem are not priority assessments for this client. The ability to pay is not included in the nursing assessment for this client.
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The nurse obtains the following vital signs on a 1-year-old child—T: 37.8°C rectal; P: 76; R: 24; BP: 92/60. The nurse evaluates vital signs as which of the following?
1. Vital signs are within normal range. 2. The client is hypothermic. 3. The client is hypertensive, and the physician should be notified. 4. The pulse is borderline low, and requires further assessment.
The nurse is providing information to a patient who has recently been diagnosed with genital herpes. Which statements indicates the need for further instruction? (Select all that apply.)
a. "I am only contagious when I have open sores." b. "The infection is limited to only my ge-nital region." c. "There is no permanent cure for this con-dition." d. "I will need to contact my physician for antibiotic cream for the open lesions whenever I have an outbreak." e. "Washing my hands is going to be a good method to prevent introduction of bacteria to the area."
The client has chronic alcoholism. Which lab test is most important for the nurse to evaluate?
1. Liver function test 2. Complete blood count 3. White blood count 4. Stool for occult blood
The nurse is caring for a woman at 28 weeks' gestation with a history of preterm delivery. Which of the following laboratory data should the nurse carefully assess in relation to this diagnosis?
a. Human relaxin levels b. Amniotic fluid levels c. Alpha-fetoprotein levels d. Fetal fibronectin levels