At a well-child visit, the parents of a 6-year-old express concerns over their child's increased complaints of fatigue. On questioning, the parent state that their child is getting 8 to 10 hours of sleep. The nurse informs the parents that:
a. This is an adequate amount of sleep
b. The child is not getting enough sleep
c. The child is getting too much sleep
d. The child needs a nap at noon
B
A 6-year-old child needs 10 to 12 hours of sleep each night. This child is not getting enough sleep. A 6-year-old is likely to be in first grade, where a nap is not possible.
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The nurse is caring for a 4-year-old girl who has been hospitalized for over a week with severe burns. Which of the following would be a priority intervention to help satisfy this preschool child's basic needs?
A) Encourage friends to visit as often as possible. B) Suggest that a family member be present with her 24 hours a day. C) Explain necessary procedures in simple language that she will understand. D) Allow her to make choices about her meals and activities as much as permitted.
A patient recovering from a total hip replacement has vital signs assessed by unlicensed assistive personnel. Which vital sign value should cause the most concern for the nurse?
1. blood pressure 110/76 2. heart rate 82 3. respiratory rate 18 4. temperature 102° F
The client has chronic obstructive pulmonary disease (COPD). Which does the nurse expect to find on physical assessment of the client? (Select all that apply.)
1. Wheezing 2. Hypercapnia 3. Upright posture 4. Small lung fields 5. Diminished chest excursion 6. Anteroposterior ratio of 1:1
Which of these assessments of an older adult, who has a urinary tract infection, requires an immediate nursing intervention?
a. Presbycusis b. Confusion c. Death of a spouse 3 months ago d. Temperature of 97.6° F