The nurse is planning to do preoperative teaching for a client and a family member, both of whom are deaf and use American Sign Language (ASL). What activities would promote learning for the client and the family? Select all that apply.

A nurse is discussing safety with a 10-year-old’s mother. Which statement by the mother neccessitates more education by the nurse?

The nurse received report about a client in labor.  The client’s assessment findings include: last vaginal examination the cervix was dilated 3cm, effaced 30%, contractions are 22 minutes apart, and last 20 seconds.  The nurse’s interpretation is that the client is in which stage of labor?

A young woman is seen in the emergency department. She states “I took a pregnancy test today. I’m pregnant. My parents will be furious with me!! I have to do something!” Which of the following responses by the nurse is most appropriate?

Use the following Case Study to answer the questions below: Kira, a 3-year-old female, is admitted to the pediatric intensive care unit (PICU) with a diagnosis of bacterial meningitis. Her parents report a 2-day history of fever, irritability, decreased appetite, and vomiting. This morning, they noticed she was less responsive and had a high-pitched cry. Initial Assessment: Vital Signs: Temp 102.8°F (39.3°C), HR 130 bpm, RR 28 breaths/min, BP 110/60 mmHg, SpO2 96% on room air Lethargic, arouses only to painful stimuli. Left pupil 4mm, sluggishly reactive to light; Right pupil 3mm, briskly reactive to light. Anterior fontanelle tense and bulging, withdraws bilateral upper and lower extremities to pain stimuli, no focal deficits noted. Gag reflex present, positive Kernig’s and Brudzinki’s signs. High pitched inconsolable crying. Skin turgor slightly decreased. Past Medical History: Full-term infant, received all age-appropriate vaccinations. No significant past medical history. No recent travel or exposure to sick contacts reported by parents other than a mild cold 1 week prior 1. Based on Kira’s initial assessment findings, which of the following is the most concerning indicator of increased intracranial pressure (ICP) in a 3-year-old? (Place answer for this question in first blank)           A. Heart rate of 130 bpm           B. Temperature of 102.8°F (39.3°C)           C. Sluggishly reactive and unequal pupils           D. Positive Kernig’s and Brudzinski’s signs 2. The nurse is developing a plan of care for Kira. Which nursing intervention is the highest priority for a patient with suspected increased ICP? (Place answer for this question in second blank)        A. Administering antipyretics to reduce fever        B. Maintaining a quiet and dimly lit environment        C. Elevating the head of the bed to 30 degrees with the head in a neutral position        D. Administering broad-spectrum antibiotics as ordered 3. The nurse is monitoring Kira for signs of worsening neurological status. Which of the following, if observed, would indicate a late and critical sign of increased ICP and impending brain herniation? (Place answer for this question in third blank)      A. Restlessness and irritability               B. Headache and nausea      C. Widening cranial sutures and increased head circumference      D. Hypertension, bradycardia, depressed/irregular respirations

A 60 year old female patient informs the nurse that she has experienced some vaginal changes since menopause. What gynecologic change is the patient most likely to report?

Which client is most likely to have an increased metabolic rate that may require nutritional interventions?

A nurse is assessing a 3-year-old child who is 1 day postoperative following a tonsillectomy.  Which of the following methods should the nurse use to determine if the child is experiencing pain?

A nurse is completing a fundal assessment including height, location, and consistency for her postpartum client. The fundus is noted to be displaced laterally to the right, and not firm. What is the priority nursing intervention?

A 5 year old child is hospitalized for a surgical procedure. The client is bed wetting. The parents report this is a new behavior and their child is toilet trained. The nurse assesses the child is exhibiting the defense mechanism of: