The nurse is observing a child with sickle cell disease. Dehydration is a common problem encountered in this disease. The nurse will observe for which of the following symptoms of dehydration:
a. Slow, pounding pulse
b. Weight gain
c. Increased urination
d. Depressed fontanels
D
A dehydrated child will have a rapid, thready pulse, decreased weight, decreased urination, and depressed fontanels.
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The nurse is assigned several patients on a pediatric postsurgical unit. For which patient would the nurse use the FLACC Postoperative Pain Tool when assessing pain?
1) A 1-month-old infant admitted for hernia repair 2) A 6-year-old patient admitted for tonsillectomy 3) A 10-year-old patient admitted for an appendectomy 4) A 13-year-old patient admitted for scoliosis surgery
One example of a research-based classification system of nursing actions is the Omaha System
A) True B) False
A patient who has been prescribed enalopril (Vasotec) has developed a persistent nonproductive cough. What is the nurse's best action?
a. Ask the prescriber to order something for the patient's cough. b. Suggest that the family bring the patient some cough drops. c. Offer the patient sips of water and ice chips. d. Hold the dose and notify the prescriber.
When you perform your nursing assessment on your medical acute-care client, she seems calm and relaxed. She readily discusses her medical condition and concerns and asks you questions
You refer her to discuss these issues in more depth with her provider. The next day you discover that she said, "I just couldn't open my mouth to say anything when the provider came in with all those medical students." Your next intervention is MOST appropriately to: a. do nothing, because the client will eventually get used to all the medical students and talk to the provider without further intervention on your part b. refer the client for a psychiatric diagnostic workup c. relieve the client of this chore by relaying the client's questions and concerns to the provider d. assess the client for social anxiety disorder