Which response does a nurse expect when testing ankle clonus of a healthy woman?
a. No movement of the foot
b. Plantar flexion of the foot
c. Extension of the lower leg
d. Dorsiflexion of the foot
ANS: A
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The nurse is caring for a patient who is hospitalized for pneumonia. Which nursing diagnosis has the highest priority?
a. Activity intolerance r/t generalized weakness and hypoxemia b. Imbalanced nutrition r/t poor appetite and increased metabolic needs c. Ineffective airway clearance r/t thick secretions in trachea and bronchi d. Knowledge deficit r/t use of nebulizer and inhaled bronchodilators
A patient's respiratory quotient is measured to be 1.1. How would the nurse interpret this information?
1. A vitamin deficiency is present. 2. The patient has the potential to retain carbon dioxide. 3. The client is not receiving enough calories. 4. The patient has fluid overload. 5. The patient is receiving too much carbohydrate.
The nurse is administering oxytocin (Pitocin). Which situation is an indication for the use of oxytocin?
a. Decreased fetal heart rate and movements b. Stimulation of contractions during labor c. Cervical ripening near term in pregnant patients d. To reverse premature onset of labor
The family history for a patient with joint pain should include information about siblings with:
a. trauma to the skeletal system. b. chronic atopic dermatitis. c. genetic disorders. d. obesity.