The nurse is caring for a 45-year-old patient who reveals that recent injuries are a result of domestic violence. The patient begs the nurse not to "tell." What action, taken by the nurse, is correct?
1. Tell the patient that the law requires reporting this incident.
2. Promise the patient not to tell anyone.
3. Talk with the patient about the reason for secrecy.
4. Report the revelation to the charge nurse.
3
Rationale: Since this patient is not a child or an elder there is not a duty to report. That duty exists only if the patient is a member of a "vulnerable population." However, the nurse should not promise the patient not to tell. The nurse should explore the reasons the patient desires to keep the information secret. The nurse should not reveal the information to anyone until further assessment is done.
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A patient's medication administration record specifies that the patient is to receive 20 units of NPH insulin at 08:00 . Before administering this medication, the nurse must do which of the following?
A) Massage the chosen injection site. B) Assess the patient's understanding of diabetes. C) Assess the patient's urine for the presence of glucose. D) Have a colleague confirm the dosage.
The nurse is caring for an infant with a temporary ileostomy. As part of the nursing plan of care, the nurse monitors for skin breakdown around the stoma
If redness occurs, which action would be most appropriate to promote healing and prevent further skin breakdown? A) Cleaning the area well with a scented diaper wipe B) Applying a barrier/healing cream or paste on the skin C) Using a barrier wafer (such as Stomahesive) to attach the appliance D) Sanitizing the area with an alcohol wipe after each diaper change
The term ________ is used to describe pain in the skeletal muscles.
Fill in the blank(s) with the appropriate word(s).
A patient asks the nurse why a quick-acting sugar given by mouth is better in the regulation of insulin than the use of intravenous glucose for a low blood sugar
Which of the following statements by the nurse represents the most appropriate response to this question? A) "The ingestion of food allows the digestive tract to stimulate vagal activity and the release of incretins." B) "The combination of insulin and food will yield a higher blood sugar than intravenous glucose." C) "Both food and intravenous glucose will produce changes similarly in the gastrointestinal tract to increase blood sugar." D) "You are mistaken. The intravenous glucose yields a higher blood glucose through the release of incretins."