You return to the room later in the shift to check on Z.O. Which of these assessment findings would cause concern? Select all that apply.
a. Blood pressure 90/55 mm Hg
b. Increased clear drainage on dressing
c. Decreased responsiveness
d. Facial edema
e. Heart rate 120 beats/min
b, c
Any clear drainage and decreased LOC should be brought to the surgeon's attention immediately
because there could be a cerebrospinal fluid (CSF) leak and decline in neurologic function.
Neurologic function should be gradually improving, not decreasing. Z.O.'s BP and HR are within
normal limits. Facial edema is not unusual after this surgery.
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A nurse observes a mother talking softly to her newborn in the pediatric clinic waiting room. The mother is also caring for her twin 2-year-olds
The twins are running around the waiting room, and the mother yells at them three times within five minutes. Which nursing diagnosis should the nurse formulate? 1. Impaired Attachment, risk for, parent/infant/child 2. Parent Anxiety related to demands of motherhood 3. Role Conflict: positive infant attachment; negative toddler attachment 4. Potential for injury of newborn related to out-of-control behavior of siblings
A patient is admitted to the ED with hallucinations. He says he has been snorting "snow." The nurse knows this is the street name for
A) cocaine. B) methamphetamines. C) heroin. D) LSD.
The nurse is assisting during a physical exam of a patient. In regards to the genital exam, what steps does the nurse need to complete? Select all that apply
A) Provide privacy. B) Instruments should be kept cold. C) Use careful draping of the patient. D) Use gloves during the exam. E) Observe breasts for deviations from normal.
Of the following topical phrases, which is most appropriate for a research study?
1. The birth rate in a city nine months after a power failure 2. The time that a nurse spends with a client in isolation as compared with the time that a nurse spends with a client who is not in isolation precautions 3. The effectiveness of caring behaviors as the most significant influence on the quality of a newly graduated nurse's orientation experience 4. The accuracy of axillary temperatures as compared with rectal temperatures of infants