The nurse asks a nursing student if any systemic signs and symptoms were present when assessing a 5-year-old client. Which answer would demonstrate that the nursing student understood?
1. Itchy, red rash
2. Vesicles present
3. Fever and headache
4. Blistering
3
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1. A rash is not a systemic sign.
2. Vesicles are not a systemic sign.
3. Systemic signs and symptoms include fever, headache, decreased responsiveness, and pain.
4. Blistering is not a systemic reaction.
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Critical thinking is an integral part of nursing care. What does critical thinking do when applied to nursing? (Mark all that apply.)
A) Enhances clinical decision making B) Identifies patient desires C) Plans the best nursing actions to assist the patients in meeting their needs D) Gradually develops independent judgments and decisions E) Helps identify patient needs
While caring for a critically ill child, the child's mother becomes distraught and begins to cry loudly while stroking the child's face. The nurse's best response to this occurrence is to:
1. Tell the mother that she needs to control herself for the benefit of her child. 2. Distract the mother by having her straighten the linens on the bed. 3. Explain the procedure that will occur with the treatment. 4. Take the mother out of the room and comfort her.
The nurse is caring for a client taking an anticoagulant. Discharge teaching for this client should include:
a. "You should avoid taking acetaminophen for pain or fever." b. "You should avoid using opioid analgesics for your postoperative pain." c. "Most anticoagulants are incompatible with oxycodone." d. "You should not take aspirin, unless specifically prescribed for you."
Which of the following is an ideal candidate for chemoprophylaxis?
A. An individual not responding to her current antibiotic treatment B. A patient with uncontrollable diarrhea C. An individual who has had a heart valve surgery and has to undergo a dental procedure D. A patient scheduled to have hip replacement surgery