The elderly client reports difficulty sleeping at night, fatigue, and lack of energy. The nurse suggests which of the following as a possible cause of the client's sleep problems?
1. Napping during the day
2. Evening walks with her spouse
3. Moderate food intake at the evening meal
4. Warm bath before bedtime
1
Rationale: Seniors can have a tendency to nap in the daytime when they get tired, and this can cause them to have trouble falling asleep or staying asleep at night. Taking an evening walk, eating moderate nighttime meals, and taking a warm bath before bedtime are all ways to promote sleep.
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A nurse is performing a focused abdominal assessment on a child complaining of stomach pain. Which assessment finding warrants immediate action by the nurse?
A. Complains of pain of 4 on 1-10 scale B. Lack of rebound tenderness C. Negative obturator sign D. Positive heel-drop jarring test
A 35-year-old male patient is admitted to the hospital with pneumonia. He was originally being treated at home, but became worse when he quit taking his antibiotic prematurely. What is an appropriate nursing diagnosis for this patient?
A) Deficient knowledge: monitoring temperature B) Noncompliance C) Risk for injury related to hypoxia D) Non-adherence: overuse
The nurse is caring for a child who is experiencing acute renal transplant rejection. Which of the following most accurately describes the expected side effects associated with the first dose of muromonab-CD3?
A) Fever with chills, chest tightness B) Cough, hyperkalemia C) Photosensitivity, GI upset D) Urinary retention, decreased appetite
The nurse is conducting the whisper test. Which nursing action is indicated?
1. Whisper directly into the patient's ears, one at a time. 2. Stand across the room from the patient. 3. Whisper words from 1 to 2 feet behind the patient. 4. Ask the patient to whisper a series of words.