During a morning assessment, the nurse notices that the patient's sputum is frothy and pink. Which condition could this finding indicate?
a. Croup
b. Tuberculosis
c. Viral infection
d. Pulmonary edema
ANS: D
Sputum, alone, is not diagnostic, but some conditions have characteristic sputum production. Pink, frothy sputum indicates pulmonary edema or it may be a side effect of sympathomimetic medications. Croup is associated with a barking cough, not sputum production. Tuberculosis may produce rust-colored sputum. Viral infections may produce white or clear mucoid sputum.
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Blood hematocrit is a measurement of
a. The oxygen-carrying ability of the red blood cells b. The total number of red blood cells in whole blood c. The percentage of blood volume of packed red blood cells d. The ratio of red blood cells to white blood cells
A hospitalized toddler was drinking from a cup at home but now refuses to drink from anything except his favorite bottle. What is the most likely reason for this behavior?
a. He is dealing with the anxiety of hospitalization by regressing. b. He is demonstrating attention-seeking behaviors because of an overabundance of attention in the hospital. c. He is attempting to refocus the attention of the adults around him to avoid further painful procedures. d. He is exhibiting normal behavior for his age, as children often stop new behaviors after they believe they have mastered them.
Data source triangulation involves collecting similar information on the topics of interest from multiple types of informants
A) True B) False
The client in the prenatal clinic tells the nurse that she is sure she is pregnant because she has not had a menstrual cycle for 3 months, and her breasts are getting bigger. What response by the nurse is best?
1. "Lack of menses and breast enlargement are presumptive signs of pregnancy." 2. "The changes you are describing are definitely indicators that you are pregnant." 3. "Lack of menses can be caused by many things. We need to do a pregnancy test." 4. "You're probably not pregnant, but we can check it out if you like."