The child with iron poisoning is given IV deforoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial flushing, and urticaria. The initial nursing intervention would be to:

• A.Discontinue the IV
• B.Stop the medication, and begin a normal saline infusion
• C.Take all vital signs, and report to the physician
• D.Assess urinary output, and if it is 30 mL an hour, maintain current treatment

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A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become increasingly restless and verbally argumentative, and her speech has become pressured. She is exhibiting signs of:

• A.Depression
• B.Agitation
• C.Psychotic ideation
• D.Anhedonia

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A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U +1 in contrast to the previous assessment of U _2. The immediate nursing response is to:

• A.Administer methergine IM
• B.Remove the retained placental fragments
• C.Assist the client to the bathroom and provide cues to stimulate urination
• D.Massage the fundus until firm

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A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from:

• A.Crying
• B.Falling asleep
• C.Rolling from his back to his tummy
• D.Sucking his thumb

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Plans for the care of a client with an ulcer caused by emotional problems need to take into consideration that:

• A.His priority needs are limited to medical management
• B.There is no real psychological basis for his illness
• C.The disorder is a threat to his physical well-being
• D.He is unable to participate in planning his care

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