A new mother had spinal anesthesia during a cesarean delivery. She now has a desire to void and can wiggle her toes. What should be the nurse's response when the mother asks to go the bathroom?
a. Assess her blood pressure
b. Obtain a wheelchair
c. Palpate her bladder
d. Put slippers on her feet
ANS: D
The nurse should check that the mother is wearing slippers to ensure better footing. If the mother has a desire to void and can move her toes, there is no need for her to remain bedridden.
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During lunch in the cafeteria, two nurses are overheard talking about their clients. One nurse states that her client actually has a warrant for his arrest waiting after he is discharged from the mental health facility. This an example of
1. assault. 2. oral defamation. 3. false imprisonment. 4. a breach of confidentiality.
A nurse discovers that a person is being abused. What should the nurse do to prevent the abuse from continuing? (Select all that apply.)
1. Appropriate assessment 2. Verbalize to the victim that he or she is a good person and the abuser is the bad person 3. Documentation 4. Intervention 5. Know the laws associated with reporting abuse
The nurse is teaching parents about instilling a positive body image for the preschool age. What statement made by the parents indicates the teaching is understood?
a. "We will make sure our child is praised about his or her looks." b. "We will help our child compare his or her size with other children." c. "We understand our child will have well-defined body boundaries." d. "We will be sure our child understands about being little for his or her age."
Which is a client with a heart rate of 170 bpm and a normal QRS duration most likely experiencing?
A. Tachydysrhythmia originating from the bundle branches. B. Tachydysrhythmia originating from the atria. C. Tachydysrhythmia originating from the ventricles. D. Tachydysrhythmia originating from the Purkinje fibers.