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Answer updated on: 12 Feb 2020
Elevate the client’s hips The client with a prolapsed cord should be treated by elevating the hips and covering the cord with a moist, sterile saline gauze. The nurse should use her fingers to push up on the presenting part until a cesarean section can be performed. Answers A, B, and D are incorrect. The nurse should not attempt to replace the cord, turn the client on the side, or cover with a ...
Answer updated on: 12 Feb 2020
The soles of the feetPetechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petichiae.
Answer updated on: 12 Feb 2020
A client with active tuberculosis is asked to wear a mask when he leaves his room to go to another department for testing.There is no need to wear gloves when feeding a client. However, universal precautions (treating all blood and body fluids as if they are infectious) should be observed in all situations. A client with active tuberculosis should be on respiratory precautions. Having the ...
Answer updated on: 12 Feb 2020
Regular developmental screening is important to avoid secondary developmental delays. Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties. Parent support groups are helpful for sharing strategies and managing health care issues.Delayed developmental milestones are characteristic of cerebral palsy, so ...
Answer updated on: 12 Feb 2020
.45 normal saline The best IV fluid for correction of dehydration is normal saline because it is most like normal serum. Dextrose pulls fluid from the cell, lactated Ringers contains more electrolytes than the clients serum, and dextrose with normal saline will also alter the intracellular fluid. Therefore, answers B, C, and D are incorrect.
Answer updated on: 12 Feb 2020
Repeated vomiting.
Increased pressure caused by bleeding or swelling within the skull can damage delicate brain tissue and may become life threatening. Repeated vomiting can be an early sign of pressure as the vomit center within the medulla is stimulated. The anterior fontanel is closed in a 4-year-old child. Evidence of sleepiness at 10 PM is normal for a four year old. The average ...
Answer updated on: 12 Feb 2020
Notify the burn emergency team.These findings are associated with systemic gram-negative infection and sepsis. This is a medical emergency and requires prompt attention.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment;
Answer updated on: 12 Feb 2020
Potential for drug dependencePatients can become dependent on barbiturates, especially with prolonged use. Because of the rapid distribution of some barbiturates, no correlation exists between duration of action and half-life. Barbiturates are absorbed well and do not cause hepatotoxicity, although existing hepatic damage does require cautions use of the drug because barbiturates are metabolized ...
Answer updated on: 12 Feb 2020
Hold the feedingUnless specifically indicated, residual amounts more than 100 mL require holding the feeding. Therefore options B, C, and D are incorrect. Additionally, the feeding is not discarded unless its contents are abnormal in color or characteristics.
Answer updated on: 12 Feb 2020
Risk for infectionAddisons disease decreases the production of all adrenal hormones, compromising the bodys normal stress response and increasing the risk of infection. Other appropriate nursing diagnoses for a client with Addisons disease include Deficient fluid volume and Hyperthermia. Urinary retention isnt appropriate because Addisons disease causes polyuria.
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