A woman's cousin gave birth to an infant with a congenital heart anomaly. The woman asked the nurse when such anomalies occur. Which of the following responses by the nurse is most accurate?
1. "We don't really know when such defects occur.".
2. "It depends on what caused the defect.".
3. "They occur between the third and fifth weeks of development.".
4. "They usually occur in the first 2 weeks of development.".
3
1. Incorrect. This is an inaccurate statement. The cardiovascular system is the first organ system to function in the developing human. The blood vessel and blood formation begin in the third week; the heart is developmentally complete in the fifth week.
2. Incorrect. Regardless of the cause, the heart is vulnerable during its period of develop-ment—in the third to fifth weeks.
3. Correct. The cardiovascular system is the first organ system to function in the developing human. The blood vessel and blood formation begin in the third week; the heart is deve-lopmentally complete in the fifth week.
4. Incorrect. The cardiovascular system is the first organ system to function in the develop-ing human. The blood vessel and blood formation begin in the third week; the heart is deve-lopmentally complete in the fifth week.
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a. Measuring and recording intake and output b. Performing a bedside dipstick urine test c. Applying a condom catheter to a male patient d. Assessing a patient's ability to collect a urine specimen e. Determining which type of catheter to insert
A patient has met the goals and outcomes mutually agreed upon for improvement of ventilatory status. What should the nurse do next?
a. Modify the care plan. b. Discontinue the care plan. c. Create a nursing diagnosis that states goals have been met. d. Reassess the patient's response to care and evaluate interventions.
The nurse interviews a female patient during admission. Which observation by the nurse identifies congruency in the patient's communication?
a. Asserts she is eager to answer questions while reading a magazine b. States that she wants information while frequently changing the subject c. Asks the nurse to explain a surgical pro-cedure while listening intently d. Explains that she is relaxed while conti-nuously shifting in her chair
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A) Restricting visitors to reduce the noise level B) Organizing nursing care at times other than visiting hours C) Asking the hospital's visitor program to call on the child to prevent loneliness D) Spending increased time with the child to prevent loneliness