A nurse is caring for a 17-year-old female patient whose left leg was amputated after being crushed in a motor vehicle accident. Which of the following interventions might the nurse perform to accommodate the patient's intellectual dimension?
A) considering the patient's developmental stage when planning nursing care
B) encouraging friends and relatives to visit often and bring games to distract her
C) teaching her how to care for the stump and explaining the rehabilitation program
D) providing the opportunity for a counselor to come in and talk to her about her loss
C
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The client with a pulmonary embolism is receiving an intravenous heparin drip. The nurse should make certain which agent is readily available?
A. Fresh-frozen plasma B. Protamine sulfate C. Cryoprecipitate D. Vitamin K
The nurse is trying to determine factors influencing a client who is not following the plan of care. Which client statement identifies a potential factor interfering with following the plan of care? Select all that apply
A) I don't drive so I was unable to fill my prescription. B) I consult the list of low sodium foods when preparing meals. C) My social security check does not come until next week. D) I dropped the strips for my finger-stick blood glucose testing in the bath water. E) "My daughter helps me with my range of motion exercises every morning and afternoon."
The nurse assesses the fluid volume status of a 72-year-old client who takes Lasix (furosemide) and Pacerone (amiodarone). Which of the following is the most reliable method for assessing this client's skin turgor?
A) Ask the client to open the mouth and examine the oral mucous membranes for dryness. B) Examine the skin on the lower legs and look for dry, scaly, or rough skin. C) Gently pinch the skin on the abdomen to see how long it takes to return to normal. D) Squeeze the skin on back of hand to see if it remains pinched or is slow to return to normal.
The nurse caring for newborns knows that infants exhibit phenomenal increases in their gross motor skills over the first 12 months of life. Which statements accurately describe the typical infant's achievement of these milestones?
Select all answers that apply. A) At 1 month the infant lifts and turns the head to the side in the prone position. B) At 2 months the infant rolls from supine to prone to back again. C) At 6 months the infant pulls to stand up. D) At 7 months the infant sits alone with some use of hands for support. E) At 9 months the infant crawls with the abdomen off the floor. F) At 12 months the infant walks independently.