The nurse, caring for a child receiving chemotherapy, notes that the child's abdomen is firm and slightly distended. There is no record of a bowel movement for the last 2 days. What do these assessment findings suggest?
a. Peripheral neuropathy
b. Stomatitis
c. Myelosuppression
d. Hemorrhage
ANS: A
Peripheral neuropathy may be signaled by severe constipation resulting from decreased nerve sensations in the bowel.
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A client with a long history of experiencing domestic violence tells the nurse, "There is no way out for me; this situation will never change." What nursing diagnosis would be most appropriate?
A) Powerlessness B) Risk for Other-Directed Violence C) Ineffective Health Maintenance D) Chronic Low Self-Esteem
In a client with sickle cell anemia, why does the nurse auscultate the lungs and heart?
A) To detect the abnormal sounds suggestive of acute chest syndrome and heart failure B) To detect the evidence of infection such as fever and tachycardia C) To detect the evidence of dehydration that might have triggered a sickle cell crisis D) To detect the motor strength and stroke-related signs and symptoms
The nurse desires to obtain as much information about clinical guidelines as possible in preparation for an educational program on evidence-based practice. Which database should the nurse use to achieve this goal?
1. Cochrane Collaboration 2. National Guideline Clearinghouse 3. PubMed from the National Library of Medicine 4. Cumulative Index of Nursing and Allied Health Literature (CINAHL)
A boy age 4 1/2 years has been having increasingly frequent angry outbursts in preschool. He is aggressive toward the other children and the teachers. This behavior has been a problem for approximately 8 to 10 weeks. His parent asks the nurse for advice
What is the most appropriate intervention? a. Refer the child for a professional psychosocial assessment. b. Explain that this is normal in preschoolers, especially boys. c. Encourage the parent to try more consistent and firm discipline. d. Talk to the preschool teacher to obtain validation for behavior parent reports.