The nurse is caring for a 5-year-old. The child's mother reports that he is extremely sensitive to sounds that most people do not notice and that he prefers complete silence
She explains that the boy is resisting going to school due to the noise and commotion. Additionally, the mother states that he will only wear 100% cotton clothing with all of the tags cut out. The nurse interprets these findings as indicating which of the following?
A) Anxiety disorder
B) Sensory integration dysfunction
C) Depression
D) Obsessive-compulsive disorder
B
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A client has a wound infection to the right arm. What comfort measure can the nurse delegate to the unlicensed assistive personnel (UAP)?
a. Elevate the arm above the level of the heart. b. Order a fan to help cool the client if feverish. c. Place cool, wet cloths on top of the wound. d. Take the client's temperature every 4 hours.
A recently licensed nurse states, "My client keeps saying he is in pain. I don't believe him because I had the same surgery last year and didn't feel nearly as bad as he claims." Which response by the more experienced nurse is most appropriate?
1. "It sounds as if your client is a drug seeker." 2. "You should contact the healthcare provider." 3. "I would call the nursing supervisor for this one." 4. "Pain differs from person to person."
To what temperature should water for eye compress be heated?
a. 95 ° F b. 110 ° F c. 115 ° F d. 120 ° F
The nurse is preparing a client for discharge with an implanted port. Instructions for site care would include:
1. No dressings are necessary. 2. Apply a sterile dressing every 2 days. 3. Place a clean bandage daily. 4. Apply a nonadhering dressing weekly.