A public health nurse is visiting a family home where there is a newborn. Which assessment finding by the nurse warrants immediate intervention?
A.
A cat is sitting on the kitchen counter by the stove.
B.
Roaches are evident in the kitchen and in the pantry.
C.
The baby is on a carpet that is stained and worn out.
D.
The crib has dirty bumper pads and a dirty comforter.
ANS: D
To prevent sudden infant death syndrome (SIDS), the American Academy of Pediatrics recommends that all babies be put to sleep on their backs and that cribs be free of toys, comforters, and bumpers. Vaccinations and breastfeeding are also recommended. The other options show a house that is dirty but does not rise to the level of needing immediate intervention.
You might also like to view...
The ICU unit has a client in which the family has been verbally abusive and has threatened staff. The manager notes an increase in absenteeism with the staff over the past 2 days. The manager believes this is attributed to a:
1. Staffing dilemma caused by the scheduler. 2. Change in the staffing matrix. 3. Decline in staff morale due to a hostile environment. 4. Miscommunication between management and nursing administration.
A nurse is teaching a young woman about healthy behaviors during the embryonic stage of pregnancy. Which of the following should the nurse emphasize to prevent congenital anomalies?
A) Adequate intake of food and fluids B) Importance of rest and sleep C) Avoid alcohol and nicotine D) Progression of stages during delivery
The nurse is caring for a client with major depression. The client tells the nurse that she "just isn't sure that life is worth living." The most appropriate nursing diagnosis for the client is:
A) Self-esteem, Low, related to depressive episode. B) Hopelessness related to symptoms of depression. C) Anxiety related to lack of energy for self-care activities. D) Thought Processes, Disturbed, related to memory loss and depression.
A student nurse is providing care for a patient who becomes short of breath while ambulating to the bathroom. The best way for the student to document this finding is to write:
1. "Patient cyanotic with ambulation." 2. "Dyspnea noted after walking 15 feet." 3. "Patient complains that he can't catch his breath." 4. "Hypoxemia present after walking to the bathroom."