The nurse is caring for an 8-year-old child who has been in a car accident, has a head injury, and is in the ICU. The nurse sees the child pulling on the IV line. What action should the nurse take?
1. Place soft wrist restraints on the child.
2. Sedate the child as needed.
3. Ask the parents to watch the child closely at all times.
4. Tell the child not to pull on the IV line.
1
Rationale:
1. Children might interfere with treatment by pulling or removing medical devices; this could necessitate restraints.
2. Due to the head injury, it is not feasible to sedate the child.
3. It is not feasible for the parents to watch the child at all times.
4. The child might not understand what the nurse is trying to convey.
Rationale:
1. Children may interfere with treatment by pulling or removing medical devices; this may necessitate the need for restraints.
2. Due to the head injury it is not feasible to sedate the child.
3. It is not feasible for the parents to watch the child at all times.
4. The child may not understand what the nurse is trying to convey.
You might also like to view...
A patient presents at the free clinic with a black, wart-like lesion on his face, stating, "I've done some research, and I'm pretty sure I have malignant melanoma."
Subsequent diagnostic testing results in a diagnosis of seborrheic keratosis. The nurse should recognize what significance of this diagnosis? A) The patient requires no treatment unless he finds the lesion to be cosmetically unacceptable. B) The patient's lesion will be closely observed for 6 months before a plan of treatment is chosen. C) The patient has one of the few dermatologic malignancies that respond to chemotherapy. D) The patient will likely require wide excision.
A nurse is frustrated because a patient does not make any needed health changes despite ongoing and comprehensive education on the health-related topic. The best action by the nurse would be to
a. ask the patient if he or she really wants to make changes. b. assess for barriers to implementing the knowledge. c. continue trying to education the patient on the topic. d. find out whether the patient learns in a different way.
Which intervention by the nurse would be the most therapeutic when a student reports witnessing a depressed teenager put a gun into a locker?
a. Call the principal and request a locker search without breaching confidentiality. b. Accompany the witness to the principal's office to further discuss what was seen. c. Call the police immediately and report that there is a student in school with a gun. d. Call the parents of the depressed teen and ask them to come and talk with their child.
Which of the following are true about the introductory phase of interviewing? Select all that apply.
A. The introductory phase is the first phase of the interviewing process. B. Introduce yourself by name and position. C. Focus on goals and move to the next topic after data is collected. D. Observe behavior and patient's self-perceptions.