A home health nurse cautions the family of a frail 82-year-old woman about the intrinsic factors that may be a potential cause of injury. Which intrinsic factors should be included? (Select all that apply.)
a. Diminished vision
b. Pet cats
c. Cluttered bedroom
d. Wearing loose house slippers
e. Generalized weakness
A, E
Diminished vision and generalized weakness are the only options related to the individual that cannot be changed (intrinsic). The other options are related to the environment and can be changed (extrinsic).
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A patient is admitted with an infected leg. The nurse notes an increase in a patient's white blood cell count. The nurse is aware that during the immune response, pathogens are engulfed by white blood cells that ingest foreign particles
What is this process known as? A) Apoptosis B) Phagocytosis C) Antibody response D) Cellular immune response
Which action best demonstrates the nurse using client-centered care when planning a menu for a Vietnamese client who is newly diagnosed with diabetes?
a. Asking the client what food he or she would eat on a standard diabetic menu b. Asking family members to make selections for the client from a diabetic menu c. Ordering a typical diabetic meal for the client and planning diet teaching d. Researching the Vietnamese culture before discussing diabetic meal planning
The nurse teaching a class on the reproductive system is discussing what happens at puberty. Which statement does the nurse make?
1. Boys and girls go through puberty at the same time. 2. Most girls develop breasts and start their menses at about the same time. 3. The nocturnal emissions that adolescent boys have contain a large number of sperm. 4. The onset and progress of puberty varies widely from person to person.
The mother of a 7-year-old child is concerned that the child will develop Reye syndrome since a family member gave the child aspirin for a headache. What should the nurse respond to the mother?
A) "This might or might not be a problem. Watch for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring the child to the emergency room immediately so an assessment for Reye syndrome can be made." B) "This is a serious problem. Aspirin is likely to cause Reye syndrome, and the child should be admitted to the hospital for observation as a precaution." C) "This is unlikely to be a problem. Half an aspirin is not enough to cause harm. Reye syndrome generally only develops from prolonged use of aspirin in connection with a virus." D) "This might or might not be a problem. Watch the child for signs of nasal discharge, sneezing, itching of the nose, or dark circles under the eyes. If you notice any of these, bring the child to the emergency room to be assessed for Reye syndrome."