after listening to the parents reports and seeing the following pediatric clients, the nurse knows
that which clent demonstrates signs of abuse that may need reporting
1. 1 year old with dyspnea, drooling, and a swolle
...
after listening to the parents reports and seeing the following pediatric clients, the nurse knows
that which clent demonstrates signs of abuse that may need reporting
1. 1 year old with dyspnea, drooling, and a swollen tongue after eating part of houseplant
2. 2 year old who is crying and has large foregead hemotoma after falling out of a chair
3. 3 year old with second degree burns afte rpulling hot tea off table
4. 5 yr old whose xray recelas 2 humerus fractures after falling from tree - ✔✔4. 5 year old
whose x ray reveal humurus fractures
rationale: the nurse should be aware of signs of abuse including repeated injuries in caried stages
of healing, shaken baby syndrome,
The nurse on an inpatient mental health unit is caring for a client with paranoid delusions who is
refusing to eat. The client states that all the food and drinks have been poisoned. Which
intervention by the nurse is appropriate?
1.
Contact the client's family and ask them to bring prepared food from home
2.
Inform the client that tube feedings will be initiated if the client refuses to eat
3.
Offer to taste the client's food and drinks while the client observes
4.
Provide the client food in unopened single-serving packages - ✔✔4. provide the client food in
unopened single serving packagesrationale: nursees caring for clients who have paranoid delusions must work to build a trusting
realtionship.
The nurse caring for a male client prepares to insert an indwelling urinary catheter. The nurse
assesses for allergies, explains the procedure to the client, and asks unlicensed assistive
personnel to perform perineal care while equipment is gathered. Place in order the steps the nurse
should take when inserting the urinary catheter. - ✔✔hand hygiene
apply sterile gloves and place drape down
use non dominant hand to grasp penis
use dominat hand to clean
use dominant hand to insert
advance catheter and inflate balloon
A client is in cardiac arrest, and resuscitation efforts are in progress when the client's spouse
arrives. The client's spouse insists on coming into the room. How should the nurse respond?
1.Allow the spouse into the room and provide a chair
2.
Call the chaplain to sit with the spouse outside the room
3.
Have the unit secretary escort the spouse to the waiting room
4.
Tell the spouse that the resuscitation is too graphic to be witnessed - ✔✔1. allow the spouse into
the room and provide a chair
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