The nurse is auscultating a newborn's heart and places the stethoscope at the point of maximal impulse at which location?
A) Just superior to the nipple, at the midsternum
B) Lateral to the midclavicular line at the fourth intercostal space
C) At the fifth intercostal space to the left of the sternum
D) Directly adjacent to the sternum at the second intercostals space
B
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A client who has myasthenia gravis (MG) has all of the following nursing diagnoses. Which would reflect the greatest threat to the client?
a. Risk for aspiration b. Impaired verbal communication c. Knowledge deficit related to disease process d. Altered urinary elimination
The finger to nose test allows assessment of:
a. coordination and fine motor function. b. point location. c. sensory function. d. stereognosis.
A nurse is planning interventions for the clients of a homeless shelter. Which of the activities represents a primary level intervention regarding sexually transmitted diseases?
1. HIV screening for all residents 2. Sex education for teenage residents 3. Treatment for residents diagnosed with AIDS 4. Gynecological referrals for female residences
A patient requests the nurse's help to the bedside commode and becomes frustrated when unable to void in front of the nurse. How should the nurse interpret the patient's inability to void?
a. The patient can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void. b. The patient does not recognize the physiological signals that indicate a need to void. c. The patient is lonely, and calling the nurse in under false pretenses is a way to get attention. d. The patient is not drinking enough fluids to produce adequate urine output.