An emergency room nurse is assessing a toddler with multiple bruises and burns. The nurse suspects the toddler has been abused. What is legally required of the nurse?
A) Nothing; the nurse has no control over the toddler's home.
B) Refer the caregivers of the toddler to a home health nurse.
C) Verbally confront the caregivers about the suspicions.
D) Report suspicions about the abuse to proper authorities.
Ans: D
Nurses are both legally and ethically obligated to report abuse, either suspected or confirmed. In many states, the failure to report actual or suspected abuse is a crime. The role of the nurse does not include confrontation.
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A woman who professes to be a strict vegetarian voices concerns about her ability to meet the nutritional needs of her fetus. Which concerns should be addressed in this session?
A) Her diet will need to have an increase in fruits and vegetables to meet the nutritional requirements of her baby. B) The supplementation of Vitamin B12 should be addressed. C) There are not special concerns for vegans as they can easily meet the dietary requirements without violating their "no meat" rules. D) She should be advised to forgo her beliefs during the pregnancy to adequately provide the nutritional requirements for her pregnancy.
An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding?
a. Yellow-tinged skin b. Orange-colored sputum c. Thickening of the fingernails d. Difficulty hearing high-pitched voices
The nurse is performing an assessment on a 2-hour-old newborn. Which finding would warrant a call to the health care provider?
a. A crepitant-like feeling when assessing the clavicles b. Blood glucose of 45 mg/dL when using a Dextrostix c. Heart rate of 160 beats/minute after vigorous crying d. Passage of a dark green substance from the intestine
An elderly client comes to the clinic after checking his blood pressure several times in the local discount store. The nurse checks the blood pressure and finds that it is 146/80. What should the nurse say to this client?
1. "Having blood pressure a little high is normal at your age. Yours is fine." 2. "I'll recheck this in a while, but your systolic pressure is too high." 3. "We'll wait and see what the doctor says, but I doubt he will be concerned." 4. "You should be on medicine for high blood pressure."