The nurse gathers the following data: BP = 150/94 mm Hg; neck veins distended; P = 104 beats/min; pulse bounding; respiratory rate = 20 breaths/min; T = 37°C (98.6°F). What disorder should the nurse suspect?
a. Hypovolemia
b. Hypercalcemia
c. Hyperkalemia
d. Hypervolemia
ANS: D
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A nurse is teaching parents how to apply "time-out" as a disciplinary method for their 4 year old. Parents have understood the teaching if they state which formula correctly guides the use of "time-out"?
a. Use the guideline of 1 minute per each year of the child's age. b. Relate the length of the time-out to the severity of the behavior. c. Never use time-out for a child younger than age 4 years. d. Follow the time-out with a treat.
Metabolic acidosis is more easily reversible and potentially less detrimental to the fetus when compared to respiratory acidosis.
a. true b. false
When a client who has a paraphilic disorder failed to help develop his plan of care, the nurse identified the nursing diagnosis noncompliance. The client stated, "Why should I help you?
You're the one who thinks there's something wrong with me." What is the etiology statement the nurse will use to complete the diagnosis? 1. Anger at being hospitalized 2. Embarrassment about his behavior 3. Fear of failing in treatment 4. Failure to recognize that a problem exists
A patient with bilateral avascular necrosis of the hips is to walk with crutches using a four-point gait for 6 weeks after her bone decompression surgeries. Which statement would indicate that the patient understands this technique?
a. "The axillary bars on the crutches should support my weight when I walk." b. "I will move both crutches and then swing my legs to the crutches—2 and 2 equals 4!" c. "I will move my right crutch and then my left leg and then the left crutch and my right leg." d. "I will move both crutches and then swing my legs through the crutches together."