The nurse is caring for an 8-year-old child with developmental delays who is unable to tie his shoes. The nurse will plan care to help this child normalize, and will develop which of the following goals?
1. Child will tie his shoes within one week.
2. Child will attempt to tie his shoes each morning when dressing.
3. Child will tie his shoes after process is demonstrated.
4. Child will wear shoes without laces.
2
Rationale: Expectations for the child must be reasonable. The child might or might not learn to tie his shoes, and the time it takes to learn will vary with individual children. However, it is possible for the child to attempt to tie his shoes, and this would be expecting behavior that is possible.
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An older man is taking aripiprazole (Abilify) for agitation. Which patient assessment is the nurse's priority to prevent catastrophic effects of the medication?
a. Oral and facial dyskinesia c. Muscle spasms of the face b. Mask facies, shuf-fling gait d. Repetitive aimless walking
A 79-year-old female resident of a long-term care facility has reported urinary frequency to the nurse. As a result, the nurse has conducted a bladder ultrasound immediately following the woman's most recent void
When assessing the resident's urinary post-void residual, the nurse should understand that: A) A post-void residual of ? 250 mL is considered normal. B) The bladder should not contain any urine after voiding. C) The volume of residual urine is dependent on the volume of the preceding void. D) There will likely be 50 to 100 mL of residual urine in the woman's bladder.
Which assessment finding suggests that your laboring client's blood magnesium level is too high?
a. Hyperactive reflexes b. Absent reflexes c. Generalized seizure d. Urine output of 60 mL/hr
Which of the following would be considered eligibility criteria for Magnet designation?
a. Chief Nursing Officer has a bachelor's degree in health administration b. Chief Nursing Officer is responsible for Department of Nursing c. The Chief Nursing Officer was promoted from a Director of Nursing position during the last six months d. The organization has full Joint Commission accreditation for two years