Which clinical manifestation does the nurse anticipate for a pediatric client who is admitted with congestive heart failure (CHF)?
1. Tachycardia
2. Weight loss
3. Hypertension
4. Bradycardia
1
Explanation:
1. Tachycardia is a sign of congestive heart failure because the heart attempts to improve cardiac output by beating faster.
2. The weight, instead of decreasing, increases, because of retention of fluids.
3. Blood pressure does not increase in CHF.
4. Bradycardia is a serious sign and can indicate impending cardiac arrest.
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A team meeting is scheduled to teach nurses about communicating with clients who are using defense mechanisms. The instructor understands that more teaching is needed when a nurse says which of the following?
1. "Defense mechanisms are not helpful and must be challenged." 2. "People use defense mechanisms every day, though they are not aware of it." 3. "Defense mechanisms are used when you feel threatened or anxious." 4. "Primitive and early-formed defenses would be stronger and more difficult to change."
The nurse is caring for a client who presents with achy jaw pain. Which assessment technique does the nurse use to determine whether the client has inflammation of the temporomandibular joint (TMJ)?
a. Checking for decayed, fractured, loose, or missing teeth b. Observing the jaw joint as the client chews a piece of food c. Palpating the joint during movement for tenderness or crepitus d. Observing for asymmetric joint protrusion when the client's mouth is closed
If the patient's food is too hot, blow on it until it cools.
Answer the following statement true (T) or false (F)
A sign the nurse observes as one indicating a liver problem is:
a. edema. b. icterus. c. non-palpable liver. d. pale lower inner canthus.