Reduction Of Risk Potential/Physiological Adaptation 1. The nurse cares for a toddler diagnosed with pneumonia receiving oxygen in an oxyben tent.

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Reduction Of Risk Potential/Physiological Adaptation 1. The nurse cares for a toddler diagnosed with pneumonia receiving oxygen in an oxyben tent. The toddler’s mother reports to the nurse that her toddler’s birthday is tomorrow and asks if the parents can have a party. It is MOST important for the nurse to follow up on which of the following statements if made by the mother? 1. “I plan to bring paper streamers to put on the wall.” 2. “My child loves to look at Mylar balloons.” 3. “I found the neatest candles to put on the cake.” 4,”My child’s grandparents are planning to come. 2. The home care nurse visits a client diagnosed with a cerebrovascular with a cerebrovascular accident with an uninhibited bladder. Which of the following actions by the nurse is MOST appropriate? 1. Encourage the client to drink 2000 ml per day. 2. Determines the client’s voiding habits before CVA. 3. Instruct the client how to perform intermittent catheterization. 4. Ask the client to void before and after meals. 3. The nurse assesses a client diagnosed with Meniere’s disease. The client’s reports that even though he takes the prescribed medications regularly, he continues to have episodes of vertigo. It is MOST IMPORTANT for the nurse to ask which of the following questions? 1. “Tell me about your diet” 2. “How are things going at work.” 3. “When were the Meniere’s disease diagnosed?” 4. “What were the results of your last blood test?” 4. A man comes to the emergency room complaining of retrosternal chest pain and shortness of breath. His blood pressure is 110/70. pulse rate 100 and irregular, respirations 28. After attaching cardiac monitor, which of the following orders should the nurse implement FIRST? 1. Take the 12-lead electrocardiogram. 2. Administer oxygen per nasal prongs. 3. Administer morphine sulfate subcutaneously. 4. Restrict his fluid and sodium intake. 5. The nurse cares for a 72 year old client diagnosed with bilateral cataracts. The client repeatedly asks the nurse, “Why did this happen to me.?” Which of the following statements by the nurse is BEST? 1. “As you age, the lenses of the eyes gradually lose moisture and their density increases.” 2. The pressure within eye gradually lose moisture and their density increases. 3. “The lenses in your eyes become hardened and inflexible.” 4. “This happened because your retina detached form the inner part of the eye.”

 
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