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- A visiting nurse is performing a family assessment of ayoung couple caring for their newborn who was diagnosedwith cerebral palsy. The nurse notes that the mother’s hairand clothing are unkempt, the house is untidy, and themother states that she is “so busy with the baby that I don’thave time to do anything else.” What would be the priorityintervention for this family?a. Arrange to have the infant removed from the home.b. Inform other members of the family of the situation. c. Increase the number of visits by the visiting nurse.d. Notify the care provider and recommend respite care forthe mother.The nurse is reinforcing teaching for the client who is scheduled for a thoracentesisWhat are three (3) teaching points that should be reinforced this client related to the thoracentesis?note that matches each definition below Chart Note PATIENT NAME: Thomas, Richard MR NUMBER: 551682 EXAMINATION DATE: August 29, 20xx SUBJECTIVE Patient complains of scrotal and genital pain. There is also dysuria often associated with purulent discharge. OBJECTIVE Richard is a sexually active 20-year-old male, who by his own admission, does not routinely use a condom. Physical exam reveals small, palpable lump on the lateral aspect of his left testis. ASSESSMENT Evaluate for gonorrhea. PLAN Culture test for gonorrhea.
- A nurse writing a post-surgical client's plan of care has included ambulation several times daily. What is the best rationale for this intervention?A nurse is teaching a 50-year-old male patient how to carefor his new ostomy appliance. Which teaching aid would bemost appropriate to confirm that the patient has learned theinformation?a. Ask Me 3b. Newest Vital Signc. Teach-back toold. TEACH acronymThe nurse is caring for a patient who is 1 hour postpartum after a normal vaginal delivery. She is receiving oxytocin to control uterine atony and postpartum hemorrhage. What does the nurse need to know about postpartum hemorrhage?
- The nurse performing a postpartum assessment on a cllent, and notes the presence of clots in the lochia. The nurse examines the clots and notes that they are multiple, larger than 1 cm. Which of the following nursing actions is the most appropriate? a. Notify the physician b. Reassess the client in two hours c. Encourage increased oral fluid intake d.Document the findingsA patient had a surgical procedure that necessitated a thoracicincision. The nurse anticipates that he will have a higherrisk for postoperative complications involving which bodysystem?a. Respiratory systemb. Circulatory systemc. Digestive systemd. Nervous systemA client who had a bladder tumor recently underwent surgery for removal of the urinary bladder with creation of an ileal conduit. An appliance is fitted over the surgical stoma.a. The nurse would monitor the client for which possible complications? b. What measures should the nurse include when providing postoperative care for this client?
- To decrease the possibility of a perineal laceration during delivery, the nurse performs which of the following interventions prior to the delivery? 1. Assists the woman into a squatting position. 2. Advises the woman to push only when she feels the urge. 3. Encourages the woman to push slowly and steadily. 4. Massages the perineum with mineral oil.Nurse Zasha in the Obstetrical Unit is monitoring Mrs. Zexy Lucero, 25 years old. G1P0. Internal examination revealed 5cm cervical dilatation, 50% effaced, +(BOW). Station 0, cephalic with a prolongation disorder for signs of fetal or maternal compromise. Which of the following assessment findings should not alert Nurse Zasha to a compromise? (Select all that apply) Coordinated uterine contractions Persistent nonreassuring fetal heart rate Maternal fatigue Uncoordinated uterine contractions Progressive changes in the cervixA group of student-nurses are about to conduct a community diagnosis. Which of the following activity is necessary during the first stage? Refer Julia immediately to an OBGyn doctor and have her checked in a hospital since she has high risk pregnancy Assist the family in providing adequate care to Julia by doing a daily home visit and Leopold’s Maneuver Discuss to Julia’s family the importance of regular prenatal check-ups Emphasize to Julia that health center services are free
