A client visits the emergency department after she was raped in her apartment. The nurse assesses the client's ability to adapt to the trauma by assessing her social support systems and which of the following?
A) Ability to effectively activate coping strategies
B) Evidence of body image disturbance
C) Type of affect reflected in nonverbal communication
D) Degree of fear response reflected in nonverbal communication
A
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The pediatrician is doing a routine physical exam on a school-aged child and tells the parents that their child has an innocent heart murmur. The parents ask the nurse what this means. The best answer is:
a. "The mitral valve is not closing tightly and some blood is getting through when the heart is not contracting." b. "If the child's heart is not overworked for the next few years, this problem will cure itself." c. "This is a minor congenital anomaly and is nothing to worry about as it will cause no problems." d. "This is the sound of blood normally flowing through the heart and is not associated with any heart problem."
Given the main functions of the autonomic nervous system (ANS), which nursing action would be a priority consideration in providing care for clients with an autonomic dysfunction?
1. Providing information for urodynamic testing 2. Monitoring cardiac rhythms 3. Performing a mental status assessment 4. Administering antacids
When the nurse communicates with a newly admitted client, the nurse must pay particular attention to nonverbal behaviors. Which of the following behaviors is the most important to pay attention to during communication?
A) Accent B) Tone of voice C) Documentation D) Education
The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is "too wet." The nurse finds the bandage and bed soaked with blood. The most appropriate initial nursing action is which of the following?
a. Notify the physician. b. Place child in Trendelenburg position. c. Apply a new bandage with more pressure. d. Apply direct pressure above catheterization site.