The home health nurse is observing the home environment for safety issues to discuss with the mother. Which observation creates a risk of injury for the toddler?
1. The mother fills the mop bucket and places it on the floor. She then leaves the room to obtain the mop.
2. When cooking, the mother only uses the back burners of the stove.
3. The mother straps her child into the high chair.
4. The mother has child-proof latches only on the cabinets containing household chemicals, medications, and poisons.
1
Rationale 1: Children can drown in 6 inches of water or less. A curious toddler may fall into the bucket and not have the dexterity to get out and drown.
Rationale 2: This is a safe practice as toddlers can reach up and pull pans off the stove or reach up and touch a hot burner.
Rationale 3: Toddlers like to climb and can be very quick. By strapping the child into the chair, the mother is reducing the risk of a fall.
Rationale 4: This is a convenience issue for the mother. If the cabinet does not contain any danger to the child, the doors do not need to be child-proof.
Global Rationale:
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A child has the following laboratory values: WBC, 7.2 mm3; bands, 4%; and neutrophils, 60%. Based on these values, which action by the nurse is the most appropriate?
A. Continue monitoring the child for infection. B. Place the child on protective isolation. C. Obtain two sets of blood cultures. D. Restrict visitors to the child.
A nurse is concerned with the chain of infection when taking care of contaminated care items. Semicritical items that require disinfection include:
a. linens. b. bedpans. c. blood pressure cuffs. d. gastrointestinal endoscopes.
A 33-year-old female complains of episodes of weakness of the left side of the face. Drooping of the left eyelid and weakness of the jaw muscle develops gradually throughout the day, and it is worse at night than the morning
The patient has a medical-surgical history of cholecystectomy at age 30. Otherwise, patient has no history of illness and takes no medications. Denies use of tobacco or alcohol. On physical examination, vital signs are T 98 degrees, 18 resps/min, pulse 66, and BP 110/60. Ptosis of the left eyelid is noted. Vision: 20/20 os, 20/20 od, and 20/20 ou. Heart: regular rate and rhythm, no murmurs. Lungs are clear to auscultation. Abdomen is non-tender with no organomegaly. Extremities: Skin is pink, cool to touch, and intact bilaterally. Left and right quadriceps muscle strength 5/5. DTRs left and right + 2/4. No clonus. Negative Homan's and Babinski's sign. Sensation to pinprick and cotton ball intact in extremities and equal bilaterally. Dorsalis pedis pulses +1/4 bilaterally. Eyelids: left-sided ptosis. No facial droop. Left and right cheek sensation to pinprick and cotton ball intact. Masseter muscle: 2/5 left versus 5/5 on right. EOMs intact. Gag reflex: uvula midline gag intact. Shrug and sternocleidomastoid muscle strength 5/5 bilaterally. Tongue: midline and strength 5/5 bilaterally. The following disorder(s) should be considered in the diagnosis: A. Bell's palsy B. Stroke C. Myasthenia gravis D. Multiple sclerosis
A mother is upset because her newborn has erythema toxicum neonatorum. The nurse should reassure her that this is what?
a. Easily treated b. Benign and transient c. Usually not contagious d. Usually not disfiguring