Nursing-Assessment

The nurse is teaching a mother about the developmental behaviors of a 7-month-old infant. Which statement by the mother indicates the need for further teaching?

"I can leave my child with my new friend for some time." Rationale: The fear of strangers increases in infants by 7 months of age. Therefore, the mother should not leave the infant with new people. The 7-month-old infant has taste preferences; therefore, the mother can try foods with different tastes for the child. The 7-month-old infant enjoys peak-a-boo games; therefore, the mother can play this game with the child. The 7-month-old infant has eruption of the upper central teeth; therefore, the mother can buy a toothbrush with soft bristles for the child to maintain oral hygiene.

On the second postpartum day a client mentions that her nipples are becoming sore from breastfeeding. What is the nurse's initial action in response to this information?

Assess her breastfeeding techniques to identify possible causes. Rationale: The nurse must first assess the client's breastfeeding practices; nipple soreness may occur when the newborn's mouth is not covering the entire areola; also, nipples must toughen in response to suckling. Providing a breast shield, having the client apply warm compresses before the feeding, or limiting the time spent at breastfeeding is premature; the cause of the soreness must be determined first and will dictate the choice of intervention.

Obesity in children is an ever-increasing problem. What should a nurse consider before confronting the problem with individual children?

Familial and cultural influences are deciding factors in eating habits. Rationale: Studies have shown that culture and family eating habits have an impact on a child's eating habits. Inheritance is not known to influence eating habits, although it is believed that hereditary factors may be associated with obesity. Childhood obesity is a known predictor of adult obesity. Although there is a trend toward asserting that children with obese parents and siblings are destined for obesity, with intervention this can be prevented.

During a newborn assessment a nurse reports a sign of respiratory distress. What clinical manifestation has the nurse identified?

Flaring nares Rationale: According to the Silverman-Anderson Index for respiratory function, flaring of the nares indicates respiratory distress; it is a compensatory mechanism to increase the intake of air. The heart rate of a newborn in respiratory distress usually remains within the normal range of 100 to 160 beats/min. Abdominal respirations are expected in the neonate; respiratory function is largely a matter of diaphragmatic contraction and expansion of the rib cage is limited in the neonate. The respiratory rate of a newborn in respiratory distress is rapid, more than 60 breaths/min. The expected respiratory rate for neonates ranges between 30 and 60 breaths/min.

A blood transfusion of packed cells has been prescribed for a client. The transfusion started five minutes ago and the client is complaining of chest pain and nausea, having difficulty breathing, and chills. The blood pressure has dropped from 140/88 to 110/60 mm Hg, temperature is 99.2 degrees, and the client seems less alert. The nurse suspects:

Hemolytic reaction. Rationale: Chest pain, nausea, having difficulty breathing, and chills are signs of hemolytic reaction, which occurs with incompatible blood. Later come symptoms of shock and loss of consciousness. This type of reaction occurs within minutes of starting the infusion. Urticarial reactions are minor allergic reactions that typically have hives. Circulatory overload typically would occur with rapid infusion and would raise the blood pressure. An anaphylactic reaction would cause respiratory or cardiac collapse.

A multigravida in active phase of labor says, "I feel all wet. I think I urinated." What should the nurse do first?

Inspect her perineal area. Rationale: Inspection of the perineum is performed to determine whether rupture of the membranes has occurred and whether the umbilical cord has prolapsed. Giving the client the bedpan is not a priority. Changing the bed linens is not the priority, although it is done eventually if the membranes have ruptured. An oral temperature should be taken after it has been established that the membranes have ruptured.

The nurse identifies that a client is expressing feelings of self-effacement. Which client assessment supports this conclusion?

Perception that no one is listening Rationale: A perception that no one is listening conveys to others that the client feels too insignificant for anyone to listen. Initiative and self-effacement are two different factors. A quiet monotone voice indicates feelings of sadness, not self-effacement. Aggressive behaviors are the opposite of self-effacing behaviors.

The client is experiencing fatigue, difficulty breathing, and dizziness. The nurse interprets which of the following dysrhythmias from the rhythm strip below from the cardiac monitor?

Sinus tachycardia Rationale: Sinus tachycardia is regular rhythm but at a rate between 110 and 150. The client may experience shortness of breath, palpitation, fatigue, and dizziness. Atrial flutter (saw-tooth waves) arises from a conduction defect in the atrium resulting in a rapid atrial rate usually between 250 to 400 times/minute. The atrial rate is faster than the atrioventricular (AV) node can conduct so that not all atrial impulses are conducted through to the ventricle. Sinus bradycardia is a regular rhythm but at a rate lower than 60 beats per minute. Atrial fibrillation is an irregular rhythm that is a result of multiple irritable foci firing in the atria and bombarding the AV node with irregular conduction of impulses through the node.

A 25-day-old infant is admitted to the hospital after 3 days of vomiting, and pyloric stenosis is diagnosed. What are the most important nursing assessments at the time of admission? Select all that apply.

Tissue turgor, Neurologic status, Amount of last voiding Rationale: It is likely that dehydration and metabolic alkalosis are present when an infant vomits for 3 days. Hydrochloric acid is lost in the vomitus. The infant will exhibit inelastic tissue turgor. It is likely that metabolic alkalosis is present when an infant vomits for 3 days. Alkalosis causes hyperreflexia, tetany, and seizures. It is likely that dehydration is present when an infant vomits for 3 days. The infant will void scanty, dark urine, indicating dehydration. The time of the last feeding and character of the vomitus are not priority assessments.

A client develops a deep vein thrombosis after surgery. Which alteration in the client's condition may indicate that the client is experiencing a pulmonary embolus?

Unilateral chest pain Rationale: Pleuritic chest pain is caused by an inflammatory reaction of lung parenchyma or by pulmonary infarction or ischemia induced by obstruction of small pulmonary arteries. Pain is sudden in onset and is exacerbated by breathing. Tachycardia, not bradycardia, occurs in an attempt to meet oxygen demands of the body and respond to increased vascular resistance in the lung. The face will be pale, not flushed, because of reduced oxygenation and possible shock. The blood pressure is not an indicator of a pulmonary embolus. However, eventual hemodynamic instability will influence blood pressure.