The nurse is teaching a pregnant 14-year-old client who is at 10 weeks' gestation about the expected body changes that will occur during pregnancy. Which client statement indicates that additional information is needed?
1. "My breasts are going to get even bigger than they've gotten over the past couple of years."
2. "My belly will gradually get more round, especially from the middle of pregnancy on."
3. "I will feel my baby move in about 16 weeks."
4. "My diet can stay the same even though I'm pregnant."
4
Explanation: 4. Because the adolescent is at risk for anemia, she will need education regarding the importance of iron in her diet.
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A client with fibromyalgia is in the hospital for an unrelated issue. The client reports that sleep, which is always difficult, is even harder now. What actions by the nurse are most appropriate? (Select all that apply.)
a. Allow the client uninterrupted rest time. b. Assess the client's usual bedtime routine. c. Limit environmental noise as much as possible. d. Offer a massage or warm shower at night. e. Request an order for a strong sleeping pill.
The nurse on third shift is handing off clients to the nurse on first shift. Which key element is most important for the third shift nurse to report during this handoff?
A) The nurse reports, "The client in room 312 continues to complain about a headache unrelieved by pain medication. I am awaiting a call from the physician for orders." B) The nurse reports on the clients in no apparent order of acuity or room number. C) The nurse reports, "The client in room 315 received an enema at 2100." D) The nurse reports, "The client in room 311 was transferred from 212."
A patient is admitted with an infected leg. The nurse notes an increase in a patient's white blood cell count. The nurse is aware that during the immune response, pathogens are engulfed by white blood cells that ingest foreign particles
What is this process known as? A) Apoptosis B) Phagocytosis C) Antibody response D) Cellular immune response
When explaining risk assessment, the nurse would indicate that the highest priority for admission to hospital-based care is
a. safety of self and others. b. confusion and disorientation. c. withdrawal from harmful substances. d. medical illness complicating a psychiatric disorder.