The nurse is identifying tertiary prevention strategies to implement for this client.
Select the three actions the nurse should take.
Insist that the client explain the reason for their bruises.
Inform the client that their child is being abusive toward them.
Report suspected maltreatment to the appropriate agency.
Confront the client's child about the client's injuries.
Ask the client how the fracture occurred.
Conduct the interview with the client privately.
Correct Answer : C,E,F
In a situation where maltreatment is suspected, it is important for the nurse to report their concerns to the appropriate agency. The nurse should also ask the client how the fracture occurred and conduct the interview with the client privately, without the presence of their child, to gather more information and assess the situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This statement shows that the client understands the threshold for high blood pressure readings. A blood pressure reading of 140/90 mmHg or higher is considered elevated or hypertensive.
It is important for the client to be aware of this value and to seek medical attention or follow the prescribed management plan if their blood pressure exceeds this threshold.
The hand should be supported at the level of the heart or positioned comfortably during blood pressure measurement, but it does not need to be specifically 6 inches below the heart.
Consistency in the timing of blood pressure measurements is important for accurate monitoring. It is generally recommended to measure blood pressure at the same time each day to account for variations that can occur throughout the day.
The blood pressure cuff should be snug but not too tight around the upper arm. It should fit comfortably and securely to ensure accurate readings.
Correct Answer is B
Explanation
This response acknowledges the client's concern and offers support and guidance. By demonstrating and encouraging the client to participate in swaddling and cuddling the newborn, the nurse promotes bonding, provides a practical solution for soothing the baby, and empowers the client to actively engage in caring for her child.
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