The nurse is assessing a 13-year-old girl who has had her first menses. Which of the following events would the nurse expect to have occurred first?
A) Evidence of pubic hair
B) Development of breast buds
C) Onset of menses
D) Growth spurt
B
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A patient has returned from back surgery. The family has brought in the patient's continuous positive airway pressure (CPAP) machine. What is the best rationale for allowing the patient to use the CPAP machine at night?
a. It will keep the patient in deep levels of REM, which will decrease the need for pain medication. b. It will help decrease hospital noise that will keep the patient awake. c. The patient needs ventilator support owing to the increased chance of postoperative respiratory complications. d. The patient needs to follow the same bedtime routine to promote a safe environment for sleep.
A baby born without a urinary bladder has a cutaneous ureterostomy with one stoma and a cutaneous ureterostomy has been surgically created. There is one stoma
Discussion with the child's family regarding care should include which of the following? 1. "This urinary diversion is permanent and urine will drain from it continuously." 2. "In the future, there will be a second surgery to offer an exit for the urine from the other kidney." 3. "This pouch needs to be changed only about once a week." 4. "You should notify the surgeon if the stoma becomes paler in color."
The nurse is assessing a newborn immediately after birth. After assigning the first Apgar score of 9, the nurse notes two vessels in its umbilical cord. What is the nurse's next action?
a. Assess for other abnormalities of the infant. b. Note the assessment finding in the infant's chart. c. Notify the health care provider of the assessment finding. d. Call for the neonatal resuscitation team to attend the infant immediately.
When following up on a client's report of hip pain during an admission assessment, the most nursing conclusive observation would be:
1. The client tearing when being ambulated to the chair 2. A report from the ancillary staff that the client is reporting pain 3. The client observed grimacing when positioning self in the bed 4. Overhearing the client discuss hip pain with family on the phone