Reference no: EM132889908

Problem 1: A nurse is assisting an infant who has respiratory syncytial virus. For which of the following findings should the nurse intervene?

a. Brisk capillary refill
b. Tachypnea
c. Rhinorrhea
d. Coughing

Problem 2: A nurse is performing a health assessment for a 6 month old infant. The nurse should begin the assessment by performing which of the following actions while the infant is quiet and sitting on the guardians lap?

a. Obtaining the infant's health history from the guardian
b. Checking the infant reflexes
c. Listening to the infinite heart and lung sounds
d. Looking in the infants eyes

Problem 3: A nurse is caring for an adolescent who has major depressive disorder. Which of the following actions should the nurse take first

a. Administer an antidepressant to the client
b. As the client if he is considering harming himself
c. Encourage the client to attend a group therapy session
d. assist the client in completing his ADLs

Problem 4: A nurse is caring for a child in the PACU following a tonsillectomy. Which of the following findings requires immediate intervention by the nurse?

a. Dark brown blood noted in emesis
b. Axillary temperature 38 C (100 F)
c. Child resorts pain level 5 on FACES scale
d. Frequent swallowing