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 B
Explanation
Before any invasive procedure, it is essential to ensure that the client has provided informed consent. Informed consent involves providing the client with information about the procedure, its risks, benefits, and alternatives, allowing them to make an informed decision about their healthcare. The nurse should verify that the client has been adequately informed about the esophagogastroduodenoscopy procedure and has given consent before proceeding.
Informing the client about the procedure duration of 60 minutes is not a priority action. While it is helpful to provide the client with information about the procedure, the specific duration of the procedure may vary depending on various factors, and it does not require immediate attention prior to the procedure.
Ensuring that the client's bladder is full is not necessary for an esophagogastroduodenoscopy procedure. The procedure involves examining the upper gastrointestinal tract and does not involve the bladder or urinary system.
Administering an oral contrast solution is not typically required for an esophagogastroduodenoscopy procedure. Oral contrast solutions are commonly used for other
diagnostic imaging procedures, such as computed tomography (CT) scans or barium studies, but not for esophagogastroduodenoscopy.
Correct Answer is D
Explanation
a.This is not recommended. The central tip of the finger is more sensitive and has more nerve endings, which can cause more pain. The recommended site for blood glucose testing is the side of the fingertip, as it is less sensitive and provides an adequate blood sample.
b. While it is not necessary to wear sterile gloves for routine capillary blood glucose monitoring, it is important to ensure that the nurse's hands are clean. Wearing clean gloves helps maintain infection control practices.
c. After puncturing the selected site, the nurse should gently squeeze the finger to create a small drop of blood. The first drop of blood should be wiped away, and subsequent drops should be used for the glucose test. This ensures that the sample is fresh and not contaminated with tissue fluid.
d.Keeping the finger in a dependent position (hanging down) helps improve blood flow to the fingertip, making it easier to obtain a sufficient blood sample. This can help ensure an accurate glucose reading.
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