The nurse is completing an admission assessment on a 3-year-old child. The child's Humpty Dumpty score is 15. Which action by the nurse is the most appropriate?
A.
Allow the child access to the play room.
B.
Classify the child as at high risk for falls.
C.
Place the child on seizure precautions.
D.
Put the child in isolation precautions.
ANS: B
A Humpty Dumpty score of 12 or above indicates a high risk for falls. The child has been classified as at high risk for falls, and nursing care should be implemented to prevent them. Access to the play room can be accomplished with almost any child. Seizures and isolation actions are not related.
You might also like to view...
While the nurse is bathing a 7-year-old child, the child states, "I get so sad when my mom leaves." The response that ignores the importance of the child's feelings is:
1. "Could you explain to me what you mean by sad?" 2. "Can you tell me more about how it makes you feel when your mom leaves?" 3. "Your mother has to take care of your brothers and sisters too. She will be back tomorrow." 4. "I will stay with you tonight while your mother is away."
A nurse teaches a client with hepatitis C who is prescribed ribavirin (Copegus). Which statement should the nurse include in this client's discharge education?
a. "Use a pill organizer to ensure you take this medication as prescribed." b. "Transient muscle aching is a common side effect of this medication." c. "Follow up with your provider in 1 week to test your blood for toxicity." d. "Take your radial pulse for 1 minute prior to taking this medication."
Which cultural belief by Cuban American pregnant patients may lead to excessive weight gain?
1) Eating coffee grounds to relieve morning sickness 2) Eating fruit to ensure a smooth complexion 3) Eating for both the mother and the fetus 4) Eating craved foods or the baby is marked by the shape of the craved food
A 1-month-old infant is left alone for extended periods, has little physical stimulation, and is malnourished
Based on this infant's history, in which phase of development according to Mahler's theory should a nurse expect to see a potential deficit? A. The symbiotic phase B. The autistic phase C. The consolidation phase D. The rapprochement phase