The nurse should plan to explain procedures and encourage selection of their own meals from hospital menus for which age group of patients?
a. Toddlers
b. Preschoolers
c. School-age children
d. Adolescents
C
School-age children are developmentally ready to accept detailed explanations. They can select their own menus and become actively involved in other areas of their care. Toddlers need routine and parent involvement for coping. Preschoolers need simple explanations of procedures. Detailed explanations and support of peers help adolescents cope.
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A client is receiving interleukins along with chemotherapy. What assessment by the nurse takes priority?
a. Blood pressure b. Lung assessment c. Oral mucous membranes d. Skin integrity
A patient is admitted to the ICU for observation of his grade II splenic laceration. Which of the following signs and symptoms would suggest that he has had a delayed rupture of his splenic capsule and is now in hemorrhagic shock?
a. BP, 110/70 mm Hg; HR, 120 beats/min; Hct, 42 mg/dL; UO, 40 mL/hr; skin that is pink, warm, and dry with capillary refill of 3 seconds b. BP, 90/70 mm Hg; HR, 140 beats/min; Hct, 21 mg/dL; UO, 10 mL/hr; pale, cool, clammy skin; confused c. BP, 100/60 mm Hg; HR, 100 beats/min; Hct, 35 mg/dL; UO, 30 mL/hr; pale, cool, dry skin; alert and oriented d. BP, 110/60 mm Hg; HR, 118 beats/min; Hct, 38 mg/dL; UO, 60 mL/hr; flushed, warm, diaphoretic skin; agitated and confused
The nurse is preparing to administer midazolam IV as a preanesthetic agent and understands that its primary purpose is to:
a. decrease pain. c. prevent respiratory depression. b. maintain blood pressure. d. provide amnesic effects.
A postpartum patient is developing a thrombophlebitis in her right leg. Which assessment should the nurse make to detect this?
A) Bend the knee and palpate the calf for pain B) Ask to raise the foot and draw a circle C) Blanch a toe and count the seconds it takes to color again D) Dorsiflex the right foot and ask if pain is in the calf