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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 discharge teaching to the parents of a child who has ADHD and a prescription for methylphenidate. Which of the following instructions should the nurse include?
- A. Administer the medication at bedtime
- B. Monitor the child’s weight frequently
- C. Give the medication with milk
- D. Discontinue the medication if insomnia occurs
Correct Answer: B
Rationale: The correct answer is B: Monitor the child’s weight frequently. This is important because methylphenidate, a stimulant used to treat ADHD, can potentially lead to appetite suppression and weight loss in children. Regular monitoring of the child's weight can help identify any significant changes and allow for appropriate interventions if needed.
Choice A is incorrect because administering the medication at bedtime can lead to insomnia due to its stimulant effects. Choice C is incorrect as there is no specific recommendation to give the medication with milk. Choice D is incorrect because insomnia is a common side effect of methylphenidate and does not necessarily warrant discontinuation of the medication unless severe or persistent.
A nurse is reviewing the laboratory results of a client who is taking lithium. Which of the following values should the nurse report to the provider?
- A. Lithium level 0.6 mEq/L
- B. Sodium 135 mEq/L
- C. Creatinine 1.5 mg/dL
- D. Potassium 4.0 mEq/L
Correct Answer: C
Rationale: The correct answer is C: Creatinine 1.5 mg/dL. Elevated creatinine levels indicate potential kidney damage from lithium toxicity. The nurse should report this value to the provider for further evaluation. Choices A, B, and D are within normal ranges and not directly related to lithium toxicity. Therefore, they do not require immediate attention.
A nurse is providing teaching to the caregiver of a client who has schizophrenia. Which of the following statements by the caregiver indicates an understanding of the teaching?
- A. I should reinforce reality when my loved one is experiencing delusions.'
- B. I should discourage my loved one from expressing feelings.'
- C. I should avoid talking to my loved one about his hallucinations.'
- D. I should encourage my loved one to isolate when symptoms occur.'
Correct Answer: A
Rationale: The correct answer is A: "I should reinforce reality when my loved one is experiencing delusions." This statement indicates an understanding of the teaching because it aligns with the therapeutic approach of reality orientation, which helps the client differentiate between reality and delusions. By reinforcing reality, the caregiver can help the client manage their symptoms effectively.
Choices B, C, and D are incorrect because they promote behaviors that are not beneficial for a client with schizophrenia. Discouraging the expression of feelings (B) can lead to emotional suppression. Avoiding discussion about hallucinations (C) may prevent the caregiver from understanding the client's experiences. Encouraging isolation (D) can worsen symptoms and hinder social interaction, which is important for recovery.
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include?
- A. Encourage group activities
- B. Provide frequent rest periods
- C. Offer high-calorie snacks
- D. Allow unlimited physical activity
Correct Answer: B
Rationale: The correct answer is B: Provide frequent rest periods. During manic episodes in bipolar disorder, individuals have high energy levels, reduced need for sleep, and increased activity levels. Providing frequent rest periods helps prevent exhaustion and promotes relaxation, which can help stabilize mood. Encouraging group activities (A) may exacerbate manic symptoms due to increased stimulation. Offering high-calorie snacks (C) can lead to poor dietary choices and worsen physical health. Allowing unlimited physical activity (D) can be dangerous as individuals in a manic state may engage in risky behaviors.
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.