The nurse has developed a plan of care for a 6-year-old with muscular dystrophy. He was recently injured when he fell out of bed at home. Which intervention would the nurse suggest to prevent further injury?
A) Recommend the bed's side rails be raised throughout the day and night.
B) Suggest a caregiver be present continuously to prevent falls from bed.
C) Encourage a loose restraint to be used when he is in bed.
D) Recommend raising the bed's side rails when a caregiver is not present.
D
Feedback:
The nurse should recommend that side rails on the bed be elevated when a caregiver is not present. The use of restraints should be avoided if at all possible. Suggesting that a caregiver be present at all times places undue stress on the family. Close observation is more appropriate. Recommending side rails be elevated at all times may be upsetting to the child and make him feel like a "baby.".
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ANS:
A teenage patient diagnosed with acne is seen in the dermatology clinic. The nurse knows that the skin lesions associated with acne include which of the following?
A) Plaque B) Pustule C) Nodule D) Vesicle
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A) Try to convince the client and family members to agree to organ or tissue donation. B) Provide nursing care to the client, without regard to the nurse's own feelings. C) Discourage the client from talking to family members about his death. D) Offer to secure spiritual counseling, if requested, for the client and family members.