A nurse is teaching the staff about antidiuretic hormone (ADH). Which information is correct in the secretion of ADH? SELECT ALL THAT APPLY
A. ADH is secreted when the circulating volume is low
B. ADH is secreted when the blood pressure is increased
C. ADH is secreted when the plasma osmolality is increased
D. ADH is secreted when the low pressure is sensed by baroreceptors
Answer: C. ADH is secreted when the plasma osmolality is increased
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The nurse is performing a sexual assessment on a newly admitted married 60-year-old female patient. Which question should the nurse omit from the nursing assessment?
a. "Are you sexually active?" b. "How often do you have sexual intercourse?" c. "Do you experience any discomfort during sex?" d. "What method of birth control are you currently using?"
During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?
A) Document the assessments and intervention. B) Reinforce the dressing with additional layers. C) Administer pain medications intramuscularly. D) Notify the physician and prepare for surgery.
Amber, a 10 year old, has been in fixed traction for a femur fracture for the past two weeks. Her parents are currently getting breakfast in the cafeteria
The nursing plan of care indicates that she should be moved every two hours and assess for skin breakdown. Today, Amber is refusing to move and tells the nurse "I am not going to do it.". The best way for the nurse to handle this situation is: 1. "I will speak with the doctor to see if we can change your orders so you do not need to be moved so often.". 2. "We will call your mother to come back and move you.". 3. "I will give you 10 minutes to think about how you want to be positioned. After that, you can ring your call light, and we will move you to the position of your choosing.". 4. "I understand that you do not want to move today, but we have to make sure you do not get any sores on your back or leg. I will let you be for 10 minutes, and then when you ring the call light, I will come in and move you to the position of your choosing.".
Nursing interventions may be categorized based upon the degree of nursing autonomy. An ex-ample of a nurse-initiated intervention is:
1. Providing client teaching 2. Administering medication 3. Ordering a liver CAT scan 4. Referring a client to physical therapy