Rectal prolapse is best assessed with the patient placed in which position?
a. lying on the stomach c. knee-chest
b. squatting d. Sims'
B
A small, symmetrical projection 2 to 4 cm long indicates a rectal prolapse. The rectal prolapse is best assessed with the patient in a squatting position. Lying on the stomach, the knee-chest, or Sims' positions is not recommended for assessing a rectal prolapse.
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What is the primary goal that the nurse should establish for a patient with an open wound?
a. The wound will remain free of infection throughout the healing process. b. The client will complete antibiotic treatment as ordered. c. The wound will remain free of scar tissue at healing. d. The client will increase caloric intake throughout the healing process.
According to Piaget, magical thinking is the belief of which?
a. Thoughts are all powerful. b. God is an imaginary friend. c. Events have cause and effect. d. If the skin is broken, the insides will come out.
A 9-month-old who is not sitting independently has been diagnosed with ataxic cerebral palsy (CP). Which of the following clinical manifestations would the nurse expect to see in the baby?
1. Hemiplegia and hypertonia 2. Hypotonia and muscle instability 3. Tremors and exaggerated posturing 4. Hypertonia and persistence primitive reflexes
A head circumference is being measured at a 4 month old's well-baby checkup. It is noted that the head circumference has not grown since the previous assessment. The nurse should:
1. Ask the mother about the child's nutrition. 2. Notify the doctor. 3. Re-measure the head circumference, check developmental milestones, assess the nutritional status, and discuss the findings with the doctor. 4. Document the normal findings.