It is suspected that a patient has an aortic aneurysm that may be dissecting or rupturing. Which assessment finding would the nurse evaluate as suggesting the aneurysm is in the thoracic region?
1. The patient has severe pain.
2. The patient becomes rapidly hypotensive.
3. Syncope occurs.
4. The blood pressure reading is different from arm to arm.
Answer: 4
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The nurse is visiting with a school-age child in the clinic. The child states to the nurse, "Friends are giving me cigarettes to smoke." What is the best response by the nurse?
1. "Tell them 'no,' don't do it again, and don't tell anyone." 2. "Smoking occasionally will not hurt you." 3. Show the child a model of lungs with smoke damage then have the child try to breathe through a straw. 4. Explain to the child the risks associated with smoking.
Teamwork is critical in the healthcare system today because:
1. health maintenance organizations and insurance companies require teamwork. 2. teams can address the diversity in care, as well as plan and process additional needs. 3. teamwork is required by the Nurse Practice Act. 4. teams are required by most healthcare regulatory agencies.
To facilitate the insertion of your gloved finger into the anal sphincter, you should instruct the patient to
a. take a deep breath and hold it. c. bear down. b. take shallow breaths. d. tighten the sphincter.
During the assessment of a 2-month-old infant's reflexes, the nurse placed a finger in the baby's hand and pressed against the palm. The baby flexed all fingers to grasp the nurse's finger. How would the nurse document this finding?
A) Plantar grasp reflex intact B) Moro reflex intact C) Support reflex intact D) Palmar grasp reflex intact