The nurse anticipates that when an infant hears a loud sudden noise, the infant will respond by:
a. Bursting into a short period of crying
b. Rapidly blinking
c. Performing the Moro reflex
d. Extending the legs
C
The Moro reflex (startle reflex) is precipitated by a loud sudden noise. This is a simple test to confirm that the infant can hear.
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A football player is thought to have sustained an injury to his kidneys from being tackled from behind
The ER nurse caring for the patient reviews the initial orders written by the physician and notes that an order to collect all voided urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important for what reason? A) Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential. B) Intake and output calculations are essential and the laboratory will calculate the precise urine output produced by this patient. C) A creatinine clearance study may be ordered at a later time and the laboratory will hold all urine until it is determined if the test will be necessary. D) There is great concern about electrolyte imbalances and the laboratory will monitor the urine for changes in potassium and sodium concentrations.
The nurse is caring for a patient who has terminal lung cancer and is unconscious. Which assessment would indicate to the nurse that the patient's death is imminent?
A) Mottling of the lower limbs B) Slow steady pulse C) Shallow breathing D) Increased swallowing
What information related to drug administration should be included in the nursing care plan? (Select all that apply.)
a. Schedule for drawing blood values b. Patient's need for crushing medication c. Patient's preference as to the use of medium in which to give crushed medicines d. Schedule of medication and dose times e. Parameters of pulse or blood pressure, if significant to administration
You care for a 6-year-old boy with acute glomerulonephritis. When planning care for him, you should be aware that glomerulonephritis usually follows an infection of what organism?
A) Group B streptococci B) Staphylococcus viridans C) A Beta-hemolytic Streptococcus D) One of the rhinoviruses