Evaluate skin integrity, (1) correct—representspreventive care for respiratory congestion resulting from anesthesia and shallowrespirations due to the abdominal incision, (4) does not address a common complication. The client's speech is difficult to understand. Aug 2015. (3) correct—adequatehydration is a priority for any client with sickle cell crisis. Establish emotional support.2. Doesthis situation require assessment? The staff maintains a calm manner when interacting with theclient.2. Administer the medication.4. Encourage the client to establish trust with one staff personwith whom therapeutic interventions should occur.2. A child returns to the recovery room after a bronchoscopy. The health care provider orders parenteralnutrition (PN), a nutritional consult, and diet recall. Which technique is correct for the nurse to use when changing a largeabdominal dressing on an incision with a Penrose drain? T or F: If you think someone slipped something in your drink and you go to a hospital emergency room, you will automatically be tested for Rohypnol and GHB. 2) CORRECT— recommendedfor exposure to general puplic, 3) CORRECT— recommendedfor people who come in contact with young children, 4) not at risk for getting the influenza from a dog, 6) CORRECT— recommendedfor people with chronic respiratory or cardiovascular disease, (1) correct—althoughthis type of response to antitussive is not uncommon in young children, itis undesirable and must be reported to the health care provider so that achange in drug therapy can be initiated, (2) is not within the realm of the nurse's scope of practice; healthcare provider must order dose changes, (4) response must be charted, and the child's intolerance to the drugdocumented and reported to other nurses; this is not enough, health care providermust be alerted so that preventive action can be taken. The client diagnosed with AIDS is seen in the emergency room with reportingmouth pain, difficulty swallowing, and a white discharge in the back of thethroat. A. Assessing for signs and symptoms of increased intracranial pressure (ICP). 1. If a fever does occur in a child after a DTaP, it usuallyoccurs within the first 2 hours. The client takesa deep breath, coughs, and then winces in pain. Administer a warm drink to the client. C. Lumbar puncture Occurrence of severe hypotension.3. The old dressing is saturated with sterile saline before itis removed. The client develops right-sided heart failure. (1) on airborne precautions during hospitalization; can send home withfamily because they are already exposed, (3) important, but not as important as taking medication, (4) correct—necessaryto take medication for 6 to 9 months. 4. The child is unable to see objects in the periphery of visualfield. Yes. The client has gained 1 pound since admission. 1. "I feel fine, but the bleeding scares me."2. 1. Strategy: "Requires an intervention" indicates you are looking for acomplication. (1) suggestive of refractive error, myopia (nearsightedness), able tosee objects at close range, (3) correct—visual axesare not parallel, so the brain receives two images, (4) suggestive of cataracts or problem with peripheral vision. Shower daily using a mild soap from a pump dispenser,and pat the skin dry.4. An elderly client is admitted to the hospital for treatment of a fracturedfemur. "I have a headache, and my stomach has bothered me for a week."3. Which observation is expected with scoliosis? Strategy: "MOST probable" indicates discrimination is required to answerthe question. Standard precautions.2. Nursing Notes: Study Guides for Various Topics, Pediatric Nursing NCLEX Practice Questions, PedsNotes: Nurse's Clinical Pocket Guide (Nurse's Clinical Pocket Guides), Pediatric Nursing: The Critical Components of Nursing Care, Arterial Blood Gas Interpretation for NCLEX (40 Questions), Arterial Blood Gas Analysis Made Easy with Tic-Tac-Toe Method, Select All That Apply NCLEX Practice Questions and Tips (100 Items), IV Flow Rate Calculation NCLEX Reviewer & Practice Questions (60 Items), EKG Interpretation & Heart Arrhythmias Cheat Sheet. Which is a correct instruction by the nurse to the parent of a 4-year-oldclient regarding collecting a specimen to be tested for pinworms? Increased radioactive iodine uptake level. (4) correct—assessment;this will help the nurse to know where the family is in regard to grieving,coping, etc. Acknowledges willing participation in an incestuous relationship.2. The patient or caregiver maintained treatment regimen to control or eliminate seizure activity. Felson and Lane 2009; Romano and De Luca 2001. Altered cardiac output related to cardiac ischemia.4. What is the age range of the majority of child victims? What is often used by perpetrators as an attempt to shift responsibility for the assault away from themselves and onto the survivor? Sit up for at least 30 minutes after eating. 1. Strategy: Determine the cause of each answer choice and how it relatesto alcohol withdrawal. A sexual assault nurse examiner, advocate, or law enforcement officer should let the pt know how long the evidence will be stored and the state's rules for disposing the kit. The nurseis most concerned if which findingis observed? No time limit for this exam. Nausea and vomiting, tachycardia, coarse tremors, seizures.4. (1) should advance cane 6–10 inches with body weight on both legs, (2) correct—should holdcane on strong side, widens base of support, reduces stress on affected side, (3) should advance cane, weaker leg, stronger leg. The informedconsent for surgery has been signed by one parent. Agitation and decreased level of consciousness.2. However, one or more of their most distressing symptoms may be manageable, e.g. A seizure results when a sudden imbalance occurs between the excitatory and inhibitory forces within the network of cortical neurons in favor of a sudden-onset net excitation. Add to folder[?] Impaired Mobility related to paralysis.2. The restraints/seclusion policies set forth by the institution.2. Doesthis situation require assessment? Administer oxygen.2. "I should induce vomiting if my child swallowslighter fluid."3. True (Not only does DNA evidence carry weight in court, but it may prevent future sexual assaults from occurring. White blood cell count (WBC) 7,000/mm3(7x109/L).4. 1. Theclient tells the clinic nurse that at home an ointment, prepared from severaldifferent herbs, is applied to the lower back to relieve the pain. Reassure the client that side effects are only temporary. Which statement bythe nurse is best? "The nurse's response should be based on which fact? The blood glucose will gradually rise because of a decreasedlevel of metabolic stress. Strategy: Determine the least stable client. 1. The nurse should anticipatethe need for which intervention? The incision is packed with sterile gauze, and then sterilesaline is poured over the dressing. The client is returned to the room after a subtotal thyroidectomy fortreatment of hyperthyroidism. Which symptom are most likelyto be observed by the nurse when a client is withdrawing from heroin? "You may think it works, but I don't believe home remedieswork."4. "Draw a picture of the eye to explain what will happen."2. Strategy: Answers are a mix of assessments and implementations. 1. Head of bed elevated 30–45°.2. Provide privacy for the client during the interview.4. The catheter would drain into a bag at the bedside or on thewheelchair.4. The nurse determines theinfant’s behaviors are consistent with which age? Evaluate the most recent vital signs recorded in the chart. Observe the wound for dehiscence.4. Obtain respirations and temperature.2. Also, this page requires javascript. Avoid abrupt changes in posture. Whichresponse by the nurse is most appropriate? Strategy: Answers are implementations. The client will begin to express reactions andfeelings about the assault before leaving the emergency room. The client's voluntary/involuntary status.4. (1) problems associated with Cushing's syndrome but are not the firstpriority, (2) problems associated with Cushing's syndrome but are not the firstpriority, (3) correct—if steroidsare withdrawn suddenly, the client may die of acute adrenal insufficiency. Women who experience unintended... After the surgery was completed, the patient was admitted to the post anesthesia care unit, which is right next to the operating room allowing for immediate ... My first case was a 45-year-old women who presented to the WSC for an abdominal hysterectomy and a cysto-stent placement to be done by Dr. Obritsch, MD. (1) client should recline for 30 minutes after eating, (3) intake of carbohydrates should be reduced along with highly spicedfoods, (4) correct—basic guidelinesto teach a postgastrectomy client are measures to prevent dumping syndrome,which include: lying down for 30 minutes after meals, drinking fluids betweenmeals, and reducing intake of carbohydrates. 1. Review the importance of adhering to a 4-hour schedule.2. Boys - 2x more likely to batter partners/ children. Place a trochanter roll on the outer aspectof the thigh.2. Changes in secondary sex characteristics. Increase the intake of high-carbohydrate foods. Quickly memorize the terms, phrases and much more. Therapeutic Communication Techniques Quiz. The newborn infant of an HIV-positive mother is admitted to the nursery.The nurse should include which intervention in the plan of care? The client eats most of the food served to her. Impaired Verbal Communication related to decrease in thoughtprocesses. The home care nurse instructs a client recently diagnosed with tuberculosis.It is MOST important for the nurseto include which as a part of the teaching plan? had a psychiatric evaluation done on her with the case of my nieces and nephew and were moving forward with the same psychiatric evaluation in this ca... During my time in clinicals on a pediatric floor, I have participated in the discharge of patients and their parents. Depression, disturbed sleep, restlessness, disorientation.3. A client diagnosed with osteoporosis reporting burning onurination.3. Yes. 1. Turn, cough, and deep breathe.2. Which nursing intervention is most beneficialin decreasing the client's pain during ambulation? You can also visit online.rainn.org to chat annonymously. The client has slight edema of the eyelids.2. Administer oxytocin parenterally as the primary IV.3. Listened to script of autobiographical trauma. Provide a safe play area for their children.4. The nurse should include whichinstructions? Doesthe assessment make sense? A client diagnosed with multiple sclerosis (MS) is at 39 weeks gestation.The client is admitted to the labor and delivery unit in active labor. Decreased resistance to stress.3. 1) CORRECT— recommendedfor people over 65. Obtain a pulse oximetry reading.2. The nurse considers the assignments appropriate if the NAPis assigned to care for which client? The client has 1+ pedal edema in both feet at the end of theday.3. The client received six units of regular insulin 3 hours ago. Lidocaine hydrochloride IV. 1. The patient or caregiver will identify and correct potential risk factors in the environment. Which behavior, if observed by the nurse, is. 3. The patient maintained effective respiratory pattern with airway patent or. (1) correct—standard,unchanging procedure, (2) requires assessment; should assign to an RN, (3) stable client with expected outcome; should assign to an LPN/LVN, (4) unstable client, requires assessment and nursing judgment; shouldassign to an RN.
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