Missed question test 13

At a well-child check, the parents of a 4-year-old child tell the nurse that they understand what their child says but others have difficulty. What is the nurse's best response?

"Your child may benefit from a referral to a speech pathologist for an evaluation."

A client admitted to the psychiatric unit describes to the nurse that during a panic attack "I feel like I am going to die, I hyperventilate, I start sweating, it feels like my heart is going to explode. The doctors say my heart is just fine. " What will be the nurse's priority intervention when the client experiences the next panic attack?

Accompany the client to the room, and remain there to provide support. When a client is having a panic attack, the nurse will stay with the client in a less-stimulating environment, such as the client's room, and maintain a calm but direct and professional manner. Because the client feels flooded with stimuli during a panic attack, the client will not be able to learn new coping techniques or verbalize triggers. Providing a medication such as a benzodiazepine should not be the first choice during a panic attack.

A postpartum mother is concerned about a noted decrease in her breast milk production. Which response by the nurse best addresses this mother's concern?

Decrease supplemental feedings with formula.

Which finding in an infant with a myelomeningocele should be reported to the health care provider (HCP) as a sign of increased intracranial pressure?

a high-pitched cry. A Chiari malformation obstructs the flow of cerebral spinal fluid resulting in hydrocephalus. This is a common problem in infants with myelomeningocele and will require surgical intervention with a shunt. A high-pitched cry is one sign of increased intracranial pressure that may indicate the presence of a Chiari malformation and requires further evaluation. Minimal movement of the lower extremities is an expected finding associated with spinal cord damage. Overflow voiding comes from a neurogenic bladder, not increased intracranial pressure. It is normal for the fontanel to bulge with crying.

A client whose job requires extensive use of a computer has developed carpal tunnel syndrome. The nurse should instruct the client to prevent which situation?

median nerve compression. Carpal tunnel syndrome is a condition in which the median nerve becomes compressed in the wrist. The brachial nerve is not affected. Carpal tunnel syndrome may be the result of a systemic disease, such as rheumatoid arthritis or diabetes mellitus, or it may be an occupational hazard for people whose jobs require repetitive hand movements such as someone who works long hours on a computer. It is not a condition resulting from disuse. The wrists do not develop flexion contractures with carpal tunnel syndrome.

The supervisor is performing a chart review. The nurse can be held legally liable for which documentation?

1200 Administered cephalosporin. The client has an allergy to penicillin -BSmith, RN. There is a cross-sensitivity between cephalosporin and penicillin, and the drug should not have been given. When a dosage range is ordered, any dose in that range is acceptable. Digoxin is a cardiac glycoside that acts to improve the efficiency of the heart and may slow the heart rate and the drug should not ordinarily be given if the apical pulse is less the 60. Mononitrate is a nitrate that can cause vasodilation and should not be given when hypotension is present.

A refugee family from the Middle East arrives with enough food and supplies to have a party for their parent, who was admitted for depression. The nurse recognizes that which factors are in play? Select all that apply.

It is the practice in some Middle Eastern countries for families to supply food and linens for their hospitalized family member. Often, immigrant families cannot tolerate hospital food, or otherwise may prefer ethnic foods brought in from home.

When caring for a client who has undergone a left lung lobectomy, what important postoperative measures related to care of chest tubes should be performed by the nurse? Select all that apply.

Measure drainage at the end of each shift. Assess chest tube dressing for bleeding. Ensure all connections are securely taped.

An admitting nurse on a rehabilitation unit notices that an elderly client with a fractured hip and severe hypothyroidism is dirty and disheveled and that their personal hygiene is very poor. As the nurse gathers admission data, the nurse further notes that the client has few personal connections, is depressed, and doesn't seem to care about personal appearance. How should the nurse improve the client's performance of self-care activities?

Provide initial and routine hygienic care, then evaluate the client daily as treatment progresses.

A nurse is caring for a pediatric client with scoliosis who has to wear a brace. The nurse should develop a teaching plan with the client to include which instruction?

Wear a form-fitting t-shirt under the brace.

When assessing a client who gave birth 12 hours ago, the nurse measures an oral temperature of 99.6° F (37.5° C), a heart rate of 82 beats/minute, a respiratory rate of 18 breaths/minute, and a blood pressure of 116/70 mm Hg. Which nursing action is most appropriate?

encouraging increased fluid intake. During the first postpartum day, mild dehydration commonly causes a slight temperature elevation; the nurse should encourage fluid intake to counter dehydration. Aspirin is contraindicated in postpartum clients because its anticoagulant effects may increase the risk of hemorrhage. Reassessing vital signs in 4 hours is sufficient to assess the effectiveness of hydration measures. The nurse should request an antibiotic order if the client's oral temperature exceeds 100.4° F (38° C), which suggests infection.

Why does the nurse plan to use both hands to assess the client's fundus in the immediate postpartum period?

to prevent uterine inversion