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A nurse in a provider’s office is assessing a school-age child who has a spiral fracture. The parent of the child provides different accounts for the cause of the injury. Which of the following actions should the nurse take first?
- A. Request that the parent leaves the room while you interview the child
- B. Report suspected abuse to child protective services
- C. Ask the child how the injury occurred
- D. Determine the immediate safety needs of the child
Correct Answer: B
Rationale: Correct Answer: B. Report suspected abuse to child protective services.
Rationale: Reporting suspected abuse to child protective services is the first step to ensure the safety and well-being of the child. In cases of conflicting stories from the parent and the child, it is crucial to prioritize the child's safety. Child protective services can investigate further to determine the true cause of the injury and provide necessary support and protection for the child.
Summary of other choices:
A: Requesting the parent to leave the room may be necessary for further assessment, but ensuring the child's safety is the priority.
C: Asking the child how the injury occurred is important but should come after ensuring the child's immediate safety.
D: Determining the immediate safety needs of the child is crucial, but reporting suspected abuse takes precedence to address potential harm.
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A nurse is providing teaching to a client who has bipolar disorder and a new prescription for lithium. Which of the following instructions should the nurse include?
- A. Take lithium on an empty stomach
- B. Avoid consuming foods high in sodium
- C. Drink 2-3 liters of water daily
- D. Increase caffeine intake
Correct Answer: C
Rationale: The correct answer is C: Drink 2-3 liters of water daily. Lithium is a mood stabilizer that can cause dehydration. Drinking an adequate amount of water helps prevent lithium toxicity and maintain proper kidney function. Choice A is incorrect because lithium should be taken with food to reduce gastrointestinal side effects. Choice B is incorrect because limiting sodium intake is not directly related to lithium therapy. Choice D is incorrect as increasing caffeine intake can lead to dehydration and worsen lithium side effects.
A nurse is planning care for a client with acute delirium. Which of the following instructions should the nurse include in the plan?
- A. Reinforce the clients orientation with the calendar
- B. Refute the clients perception of visual hallucinations
- C. Teach the client assertive techniques
- D. Assign the client to a different caregiver each shift
Correct Answer: A
Rationale: The correct answer is A: Reinforce the client's orientation with the calendar. This is because in acute delirium, the client may experience confusion and disorientation. Using a calendar can help provide structure and aid in orientation. Choice B is incorrect as refuting hallucinations may worsen the client's agitation. Choice C is incorrect as assertive techniques are not typically used in managing acute delirium. Choice D is incorrect as consistency in caregivers is important for continuity of care in delirium management.
A nurse is planning care for a client who has bipolar disorder. The client reports not sleeping for 3 days and is exhibiting a euphoric mood. The nurse should identify which of the following as the priority intervention.
- A. Secure the client’s valuable possessions
- B. Limit loud noises in the client’s environment
- C. Encourage the client to participate in structured solitary activities
- D. Provide high calorie snacks to the client
Correct Answer: D
Rationale: The correct answer is D: Provide high calorie snacks to the client. The priority intervention in this scenario is to address the client's lack of sleep and increased energy levels due to mania. Providing high-calorie snacks can help stabilize blood sugar levels and provide sustained energy, potentially aiding in promoting sleep. The other choices are incorrect because securing valuable possessions, limiting loud noises, and encouraging solitary activities do not directly address the immediate need to manage the client's symptoms related to lack of sleep and euphoria.
A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer’s disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include?
- A. Position the mattress on the floor
- B. Install sensor devices on outside doors
- C. Encourage physical activity prior to bedtime
- D. Put locks at top of doors
Correct Answer: A
Rationale: The correct answer is A: Position the mattress on the floor. Placing the mattress on the floor reduces the risk of injury if the client falls out of bed while wandering at night. This option prioritizes safety by minimizing the distance of potential falls. Installing sensor devices on outside doors (B) may alert the caregiver but does not directly address the risk of falls. Encouraging physical activity prior to bedtime (C) could increase agitation and wandering behavior. Putting locks at the top of doors (D) could pose a safety risk if emergency access is needed.
A nurse is developing a plan of care for a client who has post-traumatic stress disorder. Which of the following interventions should the nurse include?
- A. Encourage the client to suppress traumatic memories
- B. Discourage the client from discussing the trauma
- C. Encourage the client to use relaxation techniques
- D. Limit the client’s participation in activities
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to use relaxation techniques. This is important in managing symptoms of PTSD by helping the client to reduce anxiety and stress levels. Relaxation techniques, such as deep breathing and mindfulness, can help the client cope with distressing thoughts and emotions. Encouraging the client to use these techniques promotes self-soothing and emotional regulation.
Choice A is incorrect because suppressing traumatic memories can worsen symptoms and lead to increased distress. Choice B is incorrect as discussing the trauma in a safe and supportive environment is a key component of PTSD therapy. Choice D is incorrect as limiting activities can hinder the client's recovery process.