The school nurse notices a sixth-grade girl with bald patches in her hair. The hair itself is clean and shiny. Prior to referring the girl to her healthcare provider for alopecia, the nurse would want to watch the child for signs of:
1. Lice.
2. Dietary imbalances.
3. Schizophrenia.
4. Trichotillomania.
4
Rationale 1: Lice cause attachments of nits to the hair shaft, not hair loss.
Rationale 2: The nurse can assess height, weight, and BMI but will not be able to determine if dietary imbalances is the cause of the problem.
Rationale 3: Schizophrenia is a psychotic disorder whose symptoms include flat affect, loose associations, delusions, and hallucinations.
Rationale 4: Trichotillomania is the term for a condition where children pull out their hair during periods of stress.
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Helen Strauss, 81 years old, has had a CVA. The rehabilitation staff is very concerned about her insistence on doing everything herself and the resulting safety concerns. This behavior is typical of a
a. Left hemisphere CVA b. Right hemisphere CVA c. Cerebellar CVA d. Brainstem CVA
The nurse is caring for a patient with a pulmonary artery catheter
Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 125 beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO2) of 90% on a 50% venturi mask. Hemodynamic values include a cardiac output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pressure (PAOP) of 3 mm Hg. The nurse questions which of the following physician's order? a. Titrate supplemental oxygen to achieve a SpO2 > 94%. b. Infuse 500 mL 0.9% normal saline over 1 hour. c. Obtain arterial blood gas and serum electrolytes. d. Administer furosemide (Lasix) 20 mg intravenously.
A patient with a bacterial infection has been placed on antibacterial therapy. Which assessment finding in the patient indicates that the therapy is effective?
a. Red blood cell count is 4,500,000 cells/mm3. b. White blood cell (WBC) count is 8000 cells/mm3. c. Wound drainage is thick and yellow. d. Temperature is 102.4° F.
A patient has just received an upper GI series diagnostic test. Which of the following should the nurse do to help the patient after this diagnostic test?
1. keep patient on nothing by mouth status 2. keep on bed rest for 6 hours post procedure 3. monitor urine output 4. administer prescribed cathartic to aid in the expelling of the barium