What additional assessment findings might reflect the consequences of frequent prolonged
vomiting in the infant?
What will be an ideal response?
Irritability, weight loss, decreased urinary output, dry mucous membranes, lack of tearing,
sunken fontanel (depends on infant's age), poor skin turgor (might be affected by nutritional
status), lethargy (can change to coma), esophageal bleeding, pain (esophageal), decreased blood
pressure (BP) and change in pulse rate (rapid, weak to nonpalpable), change in rate and pattern
of respirations as dehydration worsens, delayed capillary refill, extremities becoming cool and
discolored
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Which routine nursing assessment is contraindicated for a client admitted with suspected placenta previa?
a. Monitoring fetal heart rate and maternal vital signs b. Observing vaginal bleeding or leakage of amniotic fluid c. Determining frequency, duration, and intensity of contractions d. Determining cervical dilation and effacement
Hydrocortisone has been prescribed to a patient for the treatment of Addison's disease, and the patient will soon be discharged. The nurse should encourage the patient to take this medication
A) at least 30 minutes before or 2 hours after meals. B) at bedtime. C) before 9 AM D) with an antacid.
Which of the following is the best indicator of a myocardial infarction?
A) Severe chest pain that radiates to the jaw and left arm B) ST segment depression on ECG C) Elevated troponin levels D) T-wave inversion
The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed
Which actions are most important to include in the patient's plan of care? (Select all that apply.) a. Make frequent neurological assessments. b. Maintain CO2 level at 50 mm Hg. c. Maintain MAP less than 130 mm Hg. d. Prepare for thrombolytic administration. e. Restrain affected limb to prevent injury.