The nurse in the prenatal clinic is seeing a pregnant 16-year-old for the first time. What comment by the young client is the most critical for the nurse to address first?
1. "My favorite lunch is burger and fries."
2. "I've been dating my new boyfriend for 2 weeks."
3. "On weekends, we go out and drink a few beers."
4. "I dropped out of school about 3 months ago."
3
Explanation: 3. The nurse responds to this most critical statement because of the danger of fetal alcohol syndrome.
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A client jumped out of a window on the second floor of the hospital and sustained a spinal cord injury that resulted in the inability to have upper and lower extremity sensation
What type of documentation by the nurse would be appropriate in this situation? A) "The client must have been depressed and wanted to commit suicide." B) "I saw the client get ready to jump and was unable to get to him fast enough." C) "Client observed standing on the window ledge; asked client to come down and proceeded to enter the room, and client jumped through the glass." D) "The previous shift should have notified the physician that the patient was suicidal."
Which method of noninvasive pain relief focuses the client's attention on something other than the pain?
a. cutaneous stimulation c. guided imagery b. distraction d. relaxation
A client with rheumatoid arthritis had abdominal surgery and has returned to the postoperative nursing unit. The client is unable to use the incentive spirometer correctly, demonstrating limited lung volume and fatiguing easily
What action by the nurse takes priority? a. Notify the physician immediately. b. Have respiratory therapy re-instruct the client. c. Assess for pain and medicate if necessary. d. Let the client rest for a few hours.
As part of therapeutic play for the patients, the pediatric nurse organizes a small skit that shows several children receiving their injections. This type of nursing intervention is beneficial for which age group?
A) Toddlers B) Preschoolers C) Adolescents D) School-aged children