The nurse admitting the adolescent client would be certain to collect data regarding:
1. Risk-taking behaviors.
2. Femur length.
3. Head circumference.
4. Adjustment to climacteric.
1
Rationale: The adolescent might engage in behaviors that puts him at risk for injury, such as smoking, drinking, and recreational drug use.
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A patient is receiving low molecular weight heparin to prevent thromboembolic complications. The nursing student asks the nursing instructor the reason why this treatment is given instead of heparin
What is the instructor's best explanation of the rationale for LMWH over heparin? A) "LMWH is associated with less thrombocytopenia than standard heparin." B) "LMWH is associated with stronger anticoagulant effects than standard heparin." C) "LMWH is given to patients who have a history of blood dyscrasia." D) "LMWH is more effective than standard heparin for patients with hypertension."
When a pregnant woman arrives at the labor suite, she tells the nurse that she wants to have an epidural for delivery. What is a contraindication to an epidural block?
a. Abnormal clotting b. Previous cesarean delivery c. History of migraine headaches d. History of diabetes mellitus
A nurse is changing an abdominal dressing on a disoriented 89-year-old man when he grabs the nurse's breast muttering something about "Mary" (his wife). What is the most therapeutic re-sponse by the nurse?
a. Stereotype him as a "dirty old man" and warn the rest of the staff to stay away from him. b. Get a physician's order for wrist restraints when nurses go near the patient for activi-ties such as dressings, baths, and feedings. c. Maintain eye contact with the patient and then clearly tell him and repeat, "I am your nurse. I am coming to help you eat, bathe, and change your stomach bandage. I am not Mary." d. "That dressing needs changing. Don't be a naughty boy with me again or I will slap your hands and call Mary to come and do all your care herself!"
Which of the following assessment findings on an African American client should be reported to the primary nurse?
A) red splinter hemorrhages on the nails B) keloid formation over an appendectomy scar C) pigmented bands on the fingernails D) a pustule on the right hand