Which assessment is most important for the client who is taking stimulant laxatives?
a. Monitor bowel elimination daily.
b. Monitor intake and output.
c. Monitor signs and symptoms of fluid and electrolyte imbalance.
d. Monitor heart rate and blood pressure every 4 hours.
Answer: c. Monitor signs and symptoms of fluid and electrolyte imbalance.
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A pediatric nurse is performing an assessment on a toddler who is suspected of having autism spectrum disorder (ASD?
When assessing the child's health history, which question to the parents would not provide adequate information to appropriately assess the toddler for this disorder? A) "Does your child have manic or depressed episodes?" B) "Tell me about your child's social interactions." C) "Does your child perform ritualistic behaviors when performing activities?" D) "Is your child able to name objects?"
Bradypnea may accompany:
a. a subconscious response to observation. b. an excellent level of cardiovascular fitness. c. ascites. d. severe pain from a rib fracture.
Prior to identifying accurate nursing diagnosis, which action MUST be taken by the nurse?
A. Reading the patients history B. Setting realistic, measurable goals C. Comparing evidence- based practices D. Clustering related patient data
The nurse is caring for a patient who is very dehydrated. Which goal best indicates that the nursing diagnosis of Deficient fluid volume has been corrected and that the patient's fluid balance has been restored?
a. The patient had 1300 mL of light yellow urine in the last 24 hours. b. The patient's lung sounds are clear bilaterally. c. The patient has no jugular venous distention. d. The patient verbalizes need for adequate daily fluid intake.