A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates which of the following?
A) Normal progression of behavior
B) Probable hypoglycemia
C) Physiological abnormality
D) Inadequate oxygenation
A
Response:
From 30 to 120 minutes of age, the newborn enters the second stage of transition, that of sleep or a decrease in activity. More information would be needed to determine if hypoglycemia, a physiologic abnormality, or inadequate oxygenation was present.
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A community health nurse has completed a community assessment and is now writing a community diagnosis for the problem. Which component of the diagnosis will be used to summarize the assessment data of the problem?
a. Identification of the health risk b. Evidence supporting the choice of priority c. The aggregate that needs the intervention d. The cause of the identified health problem
The nurse learns that a patient of the Jewish faith does not eat certain types of foods and fasts on religious holidays. What should the nurse do to ensure that this patient's needs are met?
1. Report the patient's needs to the oncoming nurse. 2. Document the patient's preferences on the assessment form. 3. Talk with the dietitian to obtain food preferences for the patient's meals. 4. Explain to the patient that eating is needed to maintain nutritional status.
Prior to beginning a connected care session, the nurse notes that several people are in the same room with the patient. What should the nurse do?
A) Continue with the session. B) Ask the patient if it is acceptable for the session to occur. C) Cancel the session and reschedule when the patient is alone. D) Ask the patient to have all other people leave the environment.
A newly admitted patient asks the nurse, "Can you hear those people laughing at me? They are making fun of me." Select the nurse's best response
a. "You are mistaken. No one is laughing at you." b. "I know the sound of laughter is real to you, but I don't hear it." c. "Your mind is playing tricks on you, making you think you hear laughter." d. "When people are mentally ill, they often experience things that others cannot relate to."