The nurse decides to spend extra time with a pregnant patient in the prenatal clinic in efforts to determine if the patient is a victim of intimate partner violence. What caused the nurse to make this plan prior to assessing the patient?
A) Patient chatting with another patient in the waiting room
B) Patient wearing a long sleeved jacket on a hot summer day
C) Patient periodically looking at a wrist watch to check the time
D) Patient unconsciously rubbing the abdomen while reading a magazine
B
Feedback:
Pregnant maltreated patients may demonstrate typical behaviors that reveal violence. A patient may dress inappropriately for warm weather, wearing long-sleeved blouses to cover up bruises on the neck or arms. A patient who is talking with another patient, checking the time on a wrist watch, and rubbing the abdomen while reading a magazine are not behaviors that indicate intimate partner violence.
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The nurse is assessing the skin of a client being admitted to the long-term care facility from an acute care facility. A small blister is noted on the client's right heel. This is documented as
1. A stage I decubitus ulcer 2. A stage II decubitus ulcer 3. A stage III decubitus ulcer 4. A stage IV decubitus ulcer
The mother of a school-age child is distraught because the child has been diagnosed with obesity. What actions should the nurse suggest to the mother to help the child with this problem? (Select all that apply.)
A) Explain that obesity will lead to an early death. B) Maintain a balanced eating approach in the home. C) Purchase books explaining the latest ways to lose weight. D) Seek out a preteen weight loss group for the child to participate. E) Encourage increased activity such as walking the dog after school.
When a client experiences an adverse reaction to a blood transfusion, the nurse should initially
a. administer oxygen via nasal prongs. b. discontinue the transfusion. c. notify the physician. d. raise the head of the bed.
What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?
a. Bathing/hygiene self-care deficit, related to altered cerebral function, as evidenced by confusion and inability to perform personal hygiene tasks b. Risk for injury, related to altered cerebral function, misperception of the environment, and unsteady gait c. Disturbed thought processes, related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear, related to sensory perceptual alterations, as evidenced by hiding from imagined ferocious dogs