The nurse anticipates what assessment finding when examining the infant with hydrocephalus?
1. Sclera seen above the iris, or "setting sun" appearance
2. Flexing of the extremities even when sleeping or resting
3. Edema of the eyelids and the lower arms and legs
4. Excess crying and irritability when picked up
1
Rationale: Infants with hydrocephalus will often be found to have setting sun appearance to the eyes. Flexing of extremities is a normal finding in term neonates.
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Clear water is used to cleanse the eyes. It is important to use proper technique when cleansing the eyes to prevent infection. What direction will the water flow when cleansing a patient's eyes?
a. Upward toward the forehead b. Downward toward the chin c. From the outer toward the inner canthus d. From the inner toward the outer canthus
The nurse is working with a group of lesbian, bisexual, and transgender women. What statements should the nurse be most concerned about regarding psychological considerations in working this group of clients? (Select all that apply.)
1. "I do not live my life openly, but I never fear someone will find out I am a lesbian." 2. "I constantly monitor everything I say and do for fear my mother will find out I am a lesbian." 3. "I constantly feel negative feelings about my sexual preference." 4. "I am coming out and sometimes I have contradictory feelings of excitement and relief." 5. "The excitement of coming out is overwhelming."
During an assessment of a client with type 2 diabetes mellitus the nurse plans interventions to address peripheral vascular disease. What information from the assessment did the nurse use to formulate this plan? (Select all that apply.)
1. Thick toenails 2. Feet cold to touch 3. Full and bounding pulses 4. Shiny skin on the lower legs 5. Legs are red when dependent
Which nursing interventions would be appropriate after angioplasty? (Select all that apply.)
a. Elevate the head of the bed by 45 degrees for 6 hours b. Assess pedal pulses on the involved limb every 15 minutes for 2 hours c. Monitor the vascular hemostatic device for signs of bleeding d. Instruct the patient bend his/her knee every 15 minutes while the sheath is in place