Which assessment findings would lead the nurse to suspect that a newborn might have a congenital heart defect? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Cyanosis
2. Heart murmur
3. Bradycardia
4. Diaphoresis
5. Tachypnea
1,2,4,5
Rationale 1: Reduced oxygenation saturation, related to unoxygenated blood entering the systemic circulation without entering the lungs, accounts for the cyanosis or blue coloration of the skin. Cyanosis indicates a possible cardiac defect.
Rationale 2: Heart murmur is abnormal extra heart sounds caused by shunting of the blood.
Rationale 3: The signs of congestive heart failure include tachycardia, not bradycardia.
Rationale 4: The signs of congestive heart failure include diaphoresis, which is often seen on the head during exertion.
Rationale 5: The signs of congestive heart failure include tachypnea, which is a respiratory rate greater than 60 breaths/min and which occurs in response to decreased lung compliance.
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The nurse is caring for a patient who just received a cancer diagnosis. The patient tells the nurse, "I saw the commercials on TV and I want to start taking Procrit immediately so I don't get tired from chemotherapy
" What is the nurse's best response? A) "Procrit is only effective if you develop anemia from chemotherapy that is caused by low levels of erythropoietin." B) "Before the doctor will order this drug, you will need to be found to have anemia so we will draw some blood for lab work while you're here." C) "Chemotherapy causes anemia and only when that happens will it be appropriate to prescribe Procrit for you." D) "The doctor may order Procrit for you when it is appropriate, but now is not the appropriate time for you to take this drug."
A client who believes she is pregnant arrives at the clinic. The APN's assessment reveals that the client has a softening of the cervix. These results are an indication of which of the following probable signs of pregnancy?
a. Chadwick's sign c. Hegar's sign b. Goodell's sign d. Ballottement
Which of the following observations by the nurse are representative of the symptomology of an epidural hematoma (EDH)? Select all that apply
1. History of unconsciousness immediately after trauma 2. Dilated pupil on the same side as the injury 3. Rapid deterioration of level of consciousness 4. Period of lucidity prior to onset of symptoms 5. Muscle weakness on the side opposite the head injury
Setting clear expectations for respectful behavior will be easier once respectful communication is the norm
Indicate whether this statement is true or false.