The correct method for counting respirations of an infant, a child, or an adult with an irregular rhythm is to:
1. count both inspiration and expiration.
2. count breathing for 15 seconds and multiply by 4.
3. observe the rise and fall of the chest, and count for 1 full minute.
4. have the client lie supine and observe the chest rise and fall for 1 minute.
ANS: 3
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A 60-year-old retiree was awakened early one morning by a police officer who informed her that her
husband had died while jogging. The next 3 days the widow went through the funeral ritual in a state of numbness. Several of her friends tried to get her to vent her feelings by crying. Which statements offer plausible explanations for the widow's inability to cry? (More than one answer may be correct.) A. The acute stage of grief involves shock and disbelief that may last for several days. B. Culture is a determinant of grief responses. Some groups view emotional displays negatively. C. Psychologically unhealthy individuals are likely to have atypical grief reactions. D. The unconscious use of denial is considered normal for several days after a loss. It protects the individual from the intolerable pain of loss.
The nurse has just finished a parent teaching session in a diverse neighborhood on preventing heat-related illnesses for children who exercise. Which statement by a parent indicates understanding of preventive techniques taught?
1. Hydration should occur at the end of an exercise session. 2. Water is the drink of choice to replenish fluids. 3. Wearing dark clothing during exercise is recommended. 4. During activity, stop for fluids every 15–20 minutes.
Which technique is suitable for an abdominal assessment?
1. Assessing painful areas first 2. Auscultating each quadrant for 5 minutes 3. Palpating lightly to locate painful and tender areas 4. Positioning the client with the arms behind the head
The nurse assesses an axillary temperature of a 2-year-old child with diarrhea. Which temperature range would be considered within normal limits for this child?
A) 34.3°C to 35.3°C B) 35.4°C to 36.9°C C) 37.0°C to 37.6°C D) 37.7°C to 38.3°C