Which are signs and symptoms the nurse should assess in the newborn that can indicate an inborn error of metabolism? (Select all that apply.)
a. Jaundice
b. Strabismus
c. Poor feeding
d. Acrocyanosis
e. Metabolic acidosis
ANS: A, C, E
Signs of inborn errors of metabolism include jaundice, poor feeding, and metabolic acidosis. Strabismus and acrocyanosis are normal findings in the newborn.
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In the nursing diagnosis Disturbed Self-Esteem related to presence of large scar over left side of face, what part of the nursing diagnosis is "presence of large scar over left side of face"?
A) etiology B) problem C) defining characteristics D) patient need
A child is brought to the emergency department with burns on the face and chest. The nurse's first priority is:
a. Assessing respiratory status b. Administering pain medication c. Removing clothing d. Inserting a Foley catheter
The damage of a Stage I pressure ulcer is much greater ____________________ the skin surface.
Fill in the blank(s) with the appropriate word(s).
A Jewish American client has been back from surgery for several hours and has not asked for pain medication. The client and nurse are from different cultural groups. Being aware of cultural influences on health behaviors, the nurse will:
A. Realize the client does not feel as much pain as some people. B. Wait for the client to ask before bringing pain medication. C. Look for nonverbal signs of pain, such as holding the incision or lying still. D. Tell the client to be sure to call her if he is in pain.