In some situations, a nurse is required by law to report findings from nurse–patient interactions or the nurse's assessment. The nurse will notify the proper authorities when which of the following occurs? Select all that apply
1. A patient admits that her husband frequently hits her and she has broken several bones.
2. An elderly patient tells the nurse that she is afraid of her grandson.
3. There are multiple bruises of varying colors on the back and abdomen of a 9-year-old.
4. An adolescent has a black eye.
5. A patient refuses to answer the nurse's question because his or her son will be mad.
ANS: 2, 3, 5
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The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal?
a. High-tone frequency loss b. Increased elasticity of the pinna c. Thin, translucent membrane d. Shiny, pink tympanic membrane
In which of the following situations would the nurse employ therapeutic communication of touch?
1. Touch is appropriate when a family member is making inappropriate comments to the nurse. 2. Touch is never appropriate in the nursing profession. 3. Touch is appropriate when an upset spouse is alone and the client has just expired. 4. Touch is appropriate when a young male client asks a young student nurse for a hug.
A dressing becomes dislodged. What can happen?
a. Microbes can enter the wound. b. Wound edges can separate. c. Dehiscence can occur. d. The wound can become larger.
A 73-year-old client shares with the nurse that she feels so useless, especially now that arthritis makes her life-long hobby of hand sewing so painful as to make it almost impossible
Which of the following nursing responses is most therapeutic given the client's current poor self-esteem image? 1. "What is it about sewing that makes it so enjoyable for you?" 2. "I'm sure your sewing is beautiful; have you ever considered teaching others to sew?" 3. "Maybe you can find something else that will give you as much satisfaction about yourself." 4. "We can attempt to find the proper pain management plan to minimize the dis-comfort so you can sew again."