The nurse is identifying tertiary prevention strategies to implement for this client.

Exhibits

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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Clients in the manic phase often exhibit inflated self-esteem, a sense of superiority, and grandiose thinking. They may have unrealistic beliefs about their abilities, accomplishments, or importance.

Hypersomnia, or excessive sleepiness, is not typically associated with the manic phase of bipolar disorder. Instead, individuals in the manic phase often experience a decreased need for sleep and may go for long periods with little or no sleep.

Blunted affect refers to a lack of emotional expression or reduced intensity of emotional responses. It is more commonly associated with depressive episodes of bipolar disorder rather than the manic phase.

Slurred speech is not a typical finding in the manic phase of bipolar disorder. However, individuals in the manic phase may exhibit rapid or pressured speech, talking excessively, rapidly switching topics, or having difficulty keeping up with their own thoughts.

A. "I understand that immunizations will be withheld if my child has lactose intolerance." B. "I can make several office visits, so my child does not get so many immunizations at once." C. "It is recommended that my child receive his first flu immunization at the age of 6." D. "My child will need to start the human papillomavirus series when he enters kindergarten."

Correct Answer is B

Explanation

This statement demonstrates an understanding of the concept of spacing out immunizations to reduce the number of shots given during a single visit. By making multiple office visits, the parent can ensure that their child receives the recommended immunizations while minimizing the number of injections at each visit.

Lactose intolerance is not a contraindication to receiving immunizations. Most vaccines do not contain lactose, and even if they do, the amount present is typically minimal and not expected to cause an adverse reaction in individuals with lactose intolerance.

The first flu immunization is typically recommended for children starting at 6 months of age, not at 6 years of age.

The human papillomavirus (HPV) vaccine is typically recommended for preteens and adolescents, usually starting between the ages of 11 and 12. It is not typically administered when a child enters kindergarten.

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The nurse is identifying tertiary prevention strategies to implement for this client. Exhibits Select the three actions the nurse should take.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is in the manic phase of bipolar disorder. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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The nurse is identifying tertiary prevention strategies to implement for this client.

Exhibits

Select the three actions the nurse should take.