A 12-year-old client is brought to the emergency room after falling on his arm during a football game
When the nurse tells the client that she is going to administer pain medication through the intravenous line, the client begins to scream and wave his unhurt arm. The parents ask the nurse why their child is behaving this way. The nurse's best response would be: 1. "He is just immature for his age."
2. "I am sure he is just scared."
3. "It looks like he may have hurt his head during the fall."
4. "He may be remembering another time when he got a shot."
4
Rationale 1: There is no information to indicate that the client is immature for age.
Rationale 2: Assuming the child is just "scared" is not something the nurse can be "sure" of, as it is never safe to assume anything as a definite.
Rationale 3: There is no information to indicate the presence of a head injury.
Rationale 4: A client's nervous system responds to pain, but many times there are also behavioral responses. A client's pain reaction may be a behavioral response to a similar or previous situation when pain was experienced. This is a learned response and method of coping with the pain. Many children remember getting a "shot" for pain, or getting an immunization. Seeing the syringe and/or needle may trigger this pain reaction.
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A) Clarify medication regimen preoperatively B) Not alter medication regimen preoperatively C) Save teaching material until after the surgery D) Not discuss fears with the patient to avoid worsening them
The nurse is caring for a 16-year-old adolescent who just delivered a baby
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When assessing a family in crisis, which of the following would the community health nurse need to do first?
A) Assess the nature of the crisis B) Determine client's perception C) Define available supports D) Assess coping abilities
A client has been admitted to the detoxification unit after binge drinking. Even though the client is not currently intoxicated, he is combative and exhibits altered thought processes. Which nursing diagnosis would be the priority?
A) Risk for Injury related to effects of alcohol abuse B) Risk for Self-Mutilation related to alcohol withdrawal and altered thought processes C) Risk for Other-Directed Violence related to alcohol withdrawal D) Risk for Delayed Development related to chronic effects of alcohol intoxication