A client who experienced a myocardial infarction has been placed on bed rest. The nurse caring for the client recognizes that the inactivity will result in certain assessment findings that include: (Select all that apply.)
1. Lethargy
2. Confusion
3. Depression
4. Poor appetite
5. Hypoactive bowel sounds
6. Decrease in baseline respiratory rate
ANS: 1, 4, 5, 6
Immobility disrupts normal metabolic functioning; decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbal-ances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peri-stalsis. Cognitive and psychological alterations are not directly caused by the inactivity.
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A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this client's plan of care to reduce discomfort?
a. Administer morphine sulfate intravenously every 4 hours as needed. b. Maintain nothing by mouth (NPO) and administer intravenous fluids. c. Provide small, frequent feedings with no concentrated sweets. d. Place the client in semi-Fowler's position with the head of bed elevated.
An appropriate nursing measure when a baby has an unexpected anomaly is to:
a. Remove the baby from the delivery area immediately. b. Tell the parents that the baby has to go to the nursery immediately. c. Inform the parents immediately that something is wrong. d. Explain the defect and show the baby to the parents as soon as possible.
When administering an oral medications to an infant what should the nurse keep in mind?
A) The infant will take oral medications more readily after being fed B) The infant will take medications more readily if allowed to move the head as desired C) The oral medication should be placed along the side of the mouth when using a syringe or dropper D) The infant will take a medication more readily if the flavor is disguised
A female patient, who is in her late 30s, is describing her home life to the nurse. The nurse determines that the patient is a member of the sandwich generation based on which of the following?
A) She has a young adult child at home and an elderly parent to care for at the same time. B) She has a young adult child who is married and currently living away from home. C) She has a young adult child away at college and without any living parents. D) She has no responsibilities associated with her young adult children or her parents.