A symptom often seen in the child diagnosed with Haemophilus influenzae meningitis is a stiff neck. How should the nurse document this finding?
A) Opisthotonos
B) Nuchal rigidity
C) Encephalopathy
D) Purpuric rash
Ans: B
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In an assessment of a patient who has been receiving IV fluids for the last 6 hours, the nurse finds that the pulse is now bounding, the blood pressure is more than 15 mm Hg higher than the last reading, and there is pedal edema
The nurse evaluates these signs as associated with: 1. infiltration of the IV site. 2. vascular fluid volume excess. 3. pulmonary air embolism. 4. phlebitis of the leg veins.
The nurse preparing to insert an IV on an older adult client notices that the client's skin is extremely fragile. Which action by the nurse is best?
a. Use a blood pressure cuff to cause the vein to distend. b. Slap the skin vigorously to cause the vein to rise. c. Place a gauze pad under the tourniquet before tightening. d. Avoid the use of a tourniquet if the vein is already hard.
Which is an appropriate nursing measure when a baby has an unexpected defect?
a. Remove the baby from the delivery area immediately. b. Inform the parents immediately that something is wrong. c. Tell the parents that the baby has to go to the nursery immediately. d. Explain the defect and show the baby to the parents as soon as possible.
Which of the following statements best describes iron deficiency anemia in infants?
a. It is caused by depression of the hematopoietic system. b. It is easily diagnosed because of infant's emaciated appearance. c. It results from a decreased intake of milk and the premature addition of solid foods. d. Clinical manifestations are related to a reduction in the amount of oxygen available to tissues.