The nurse is assessing the neurological status of an 8-month-old infant. Which reflexes would the nurse expect to find intact?
a. Grasp
b. Extrusion
c. Pincer
d. Parachute
D
The grasp and extrusion reflexes disappear at around 3 months. The pincer reflex is not well established until 12 months.
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A patient has had multiple blood pressure readings that indicate he has hypertension. How is hypertension defined?
A) Systolic pressure above 140 mm Hg or diastolic pressure above 90 mm Hg B) Systolic pressure above 160 mm Hg or diastolic pressure above 110 mm Hg C) Systolic pressure above 130 mm Hg or diastolic pressure above 95 mm Hg D) Systolic pressure above 150 mm Hg or diastolic pressure above 100 mm Hg
The postsurgical patient has a painful and swollen right calf that appears to be larger than the calf of the left leg. What is the nurse assessing for when she flexes the patient's right leg and dorsiflexes the foot?
a. Pain, which would be a positive Homans sign b. Muscular spasm, which would be a sign of hypocalcemia c. Rigidity, which would be a sign of ankylosis d. Crepitus, which would be a sign of a joint disorder
The nurse is caring for a patient with suspected shift work disorder. In order for the patient to be diagnosed with this disorder, what must criteria must the patient meet?
1. The criteria for at least one other physiological disorder 2. Sleep loss of more than 2 hours per day due to the shift work 3. The criteria for other sleep circadian-rhythm disorders 4. Absence of any physiological disorders that may cause the symptoms
Nurses should be aware that accelerations in fetal heart rate are:
1. indications of fetal well-being when they are periodic. 2. are greater and longer in preterm gestations. 3. are usually encountered with breech presentations when they are episodic. 4. may visibly resemble the shape of the uterine contraction.