The nurse interviews a client admitted for an outpatient procedure and enters a long list of home medications into the medical record.

The nurse observes several medications that are prescribed for the same indications.

Which instruction is best for the nurse to communicate to the client regarding the multiple prescriptions?

A - The injury may require medical attention, as the mother mentioned that the boy is in pain. Correct

This is the correct answer, as it reflects the nurse's assessment of the injury and the appropriate action to take. The nurse should consider the mother's report of pain as a valid indicator of the severity of the injury, and should not dismiss or minimize it.

The nurse should also observe the boy's arm and shoulder for any signs of fracture, dislocation, swelling, bruising, or deformity, and ask him to rate his pain on a scale of 0 to 10. The nurse should then decide whether to refer the boy to a physician or an emergency department for further evaluation and treatment.

B - The abrasions on the boy's leg and hand have healed.

This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The abrasions on the boy's leg and hand are not relevant to his current complaint of arm and shoulder pain, and do not indicate whether he needs medical attention or not. The nurse should focus on the boy's primary concern and not distract him with unrelated questions or comments.

C - The mother describes what she did after her child got injured.

This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The mother's description of what she did after her child got injured may provide some useful information, such as how long ago the injury occurred, what first aid measures were applied, and whether there was any improvement or worsening of symptoms. However, it does not directly answer the question of whether the injury requires medical attention or not. The nurse should listen to the mother's account, but also perform a physical examination and ask relevant questions to assess the injury.

D - The boy lacks coordination when answering the nurse's questions.

This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The boy's lack of coordination when answering the nurse's questions may indicate a possible head injury, concussion, or shock, which are serious complications that require immediate medical attention. However, it does not directly relate to his arm and shoulder pain, which is his main complaint.

The nurse should assess the boy's mental status and neurological function, but also evaluate his arm and shoulder for any signs of damage or inflammation.

The correct answer is choice d. Activate the lockdown procedure.

Choice A rationale:

Asking the mother if any visitors were expected to arrive is important for gathering information, but it is not the immediate priority when a newborn is missing. The primary concern is to ensure the safety and security of the infant.

Choice B rationale:

Matching ID bands of all infants and mothers on the unit is a crucial step in verifying the identity of the newborn, but it should be done after ensuring that the unit is secure and the baby cannot be taken out of the facility.

Choice C rationale:

Determining if the newborn is in the nursery is also important, but it should be done after securing the unit to prevent any potential abduction.

Choice D rationale:

Activating the lockdown procedure is the first and most critical action. This ensures that all exits are secured, preventing anyone from leaving the unit with the infant. It is a safety measure to protect the newborn and is the immediate priority in such situations.