The nurse is providing anticipatory guidance instructions to the parents of a newborn. Which of these instructions should the nurse give as disease/injury prevention strategies? Standard Text: Select all that apply
1. SIDS risk reduction
2. Fall prevention
3. Formula safety
4. Immunization schedule
5. Risk of poisoning
1,2,3,4
Rationale 1: SIDS is a major concern of infancy, and information on SIDS prevention, including back sleeping and the use of fans for air movement, should be provided.
Rationale 2: Anticipatory guidance should be given about fall prevention. Newborns are incapable of protecting themselves from falls and must always be placed in a secure environment, including the use of bed rails and safety straps when appropriate.
Rationale 3: Parents must be instructed on safe handling of formula including preparation and storage guidelines.
Rationale 4: It is important for parents to understand the recommended vaccination schedules and to comply with these standards to protect their child from childhood illnesses.
Rationale 5: It is too early for a discussion on the risk of poisoning. Until the child is mobile, poisoning is not a high priority for client teaching.
Global Rationale:
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A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance?
a. "I will allow my spouse to change my dressings." b. "I want to have surgical reconstruction." c. "I will bathe and dress before breakfast." d. "I have secured the pressure dressings as ordered."
The nurse completes a physical assessment of a newborn. Which finding should the nurse identify as being abnormal?
A) Abdomen slightly protuberant B) Clear drainage at the base of the umbilical cord C) Bowel sounds present at two to three per minute D) Liver palpable 2 cm under the right costal margin
The nurse is planning care for a patient with fluid volume overload and hyponatremia. Which intervention should be included in this patient's plan of care?
1. Restrict fluids. 2. Administer intravenous fluids. 3. Provide Kayexalate. 4. Administer intravenous normal saline with furosemide.
A patient on didanosine telephones to report the recent onset of abdominal pain, nausea, and vomiting. Select the nurse's best course of action
1. Reassure the patient that viral gastroenteritis is likely and should be self-limiting. 2. Stop the medication until the symptoms are resolved, and restart as prescribed. 3. Advise the patient to come to the clinic immediately to be evaluated for pancreatitis. 4. Provide antiemetics and give instructions for clear liquids until the symptoms resolve.