A nurse is reinforcing teaching with a newly licensed nurse regarding sources of medication information. Which of the following resources should the nurse include as reliable references for the nurse to use to evaluate medication information? (Select all that apply.)(Select All that Apply.)

Explanation:

A. Place the head of the client's bed flat:

This action is not appropriate because lying flat can worsen dyspnea in many cases. It can restrict lung expansion and make breathing more difficult. Instead, the nurse should elevate the head of the bed or position the client in a semi-Fowler's or high-Fowler's position to facilitate easier breathing.

B. Perform nasotracheal suctioning for the client:

Nasotracheal suctioning is not indicated for dyspnea unless there is a specific medical reason, such as airway obstruction or excessive secretions. Performing suctioning without a clear indication can cause discomfort and may not address the underlying cause of dyspnea.

C. Increase the heat in the client's room:

Adjusting the room temperature is generally not a direct intervention for dyspnea. While maintaining a comfortable environment is important, dyspnea is usually managed through other means such as medication and positioning.

D. Administer an opioid narcotic to the client:

This is the most appropriate action among the choices provided. Opioid narcotics, such as morphine, are commonly used to alleviate dyspnea in end-of-life care. They help reduce the sensation of breathlessness, calm respiratory distress, and improve overall comfort for the client.

Explanation:

A. "I promise I won't tell anyone about this."

This statement is not appropriate because nurses are mandated reporters of suspected child abuse. Promising confidentiality in cases of abuse goes against legal and ethical responsibilities. The nurse must report suspected abuse to the appropriate authorities for the safety and well-being of the child.

B. "Your family is bad for doing this to you."

This statement is judgmental and may make the child feel guilty or conflicted about their family. It is essential to avoid blaming or shaming language when addressing a child who has been abused. The focus should be on providing support, validation, and appropriate intervention.

C. "Let's discuss what you have told me with your family members."

This statement is not appropriate because it suggests involving the family members in the discussion of abuse, which can potentially put the child at risk of further harm. It's essential to prioritize the safety of the child and follow appropriate reporting procedures rather than involving potentially abusive family members in discussions about abuse.

D. "It is not your fault that this happened."

This statement is appropriate and supportive. It reassures the child that they are not to blame for the abuse they have experienced. It acknowledges the child's feelings and helps them understand that they are not responsible for the actions of the abuser. This statement can provide comfort and validation to the child during a difficult time.