The nurse should include which of the following factors in a pain assessment? (Select all that apply.)
a. Initiator of pain
b. Location of pain
c. Radiation of pain
d. Severity of pain
e. Frequency of pain
ANS: A, B, C, D, E
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A child has been diagnosed with an atrioventricular canal defect (AVC). While awaiting surgical correction, which teaching takes priority?
A. Care of tubes and drains postoperatively B. Feeding the child frequent, small amounts C. Monitoring weight gain and urine output D. Returning for all scheduled appointments
After the insertion of a central venous catheter for total parenteral nutrition, the patient demonstrates dyspnea with complaints of chest pain radiating to the back
Which of the following should the nurse suspect is occurring with this patient? 1. catheter fracture 2. arterial puncture 3. air emboli 4. pneumothorax
A nursing group has been very successful in achieving its goals even though the group has lacked leadership. Which of the following factors is probably most responsible for the group's success in goal achievement?
a. Life experience c. Informal organizational structures b. Extrinsic satisfaction d. Cohesive groups
The client in the prenatal clinic tells the nurse that she is sure she is pregnant because she has not had a menstrual cycle for 3 months, and her breasts are getting bigger. What response by the nurse is best?
1. "Lack of menses and breast enlargement are presumptive signs of pregnancy." 2. "The changes you are describing are definitely indicators that you are pregnant." 3. "Lack of menses can be caused by many things. We need to do a pregnancy test." 4. "You're probably not pregnant, but we can check it out if you like."