What should the nurse do when caring for a victim of abuse? (Select all that apply.)
1. Ensure the client's safety
2. Support the client
3. Empower the client to take control
4. Avoid the team approach when assessing the patient
5. Provide information regarding available services for the patient
Correct Answer: 1, 2, 3, 5
Intervention is very important to remove a victim from a violent environment. Once a trusting nurse-client relationship is established, the victim can feel safe and supported and take responsibility to take the necessary steps to remove him or herself from a violent situation. Since the nurse may be the only person the patient has contact with the nurse should provide information regarding available services for the patient. If the nursing assessment reveals abuse, a team assessment should take place to assess both the physical and emotional status of the patient.
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The nurse is planning care for a pediatric client recovering from surgery to repair a congenital heart defect. Which intervention should the nurse include to support the client's fluid status?
A) Encourage fluids. B) Limit fluids. C) Monitor pain. D) Maintain intravenous therapy until day before discharge.
A client is in the hospital for heart failure and respiratory management. During a focused assessment, the nurse notes that the client coughs frothy pink sputum. The immediate intervention by the nurse would be to:
1. Place the client in a high Fowler's position. 2. Ask the laboratory to obtain an arterial blood gas. 3. Notify the physician. 4. Stop the administration of oxygen.
Which of the following is an advantage that nurses have in treating young children who have been sexually abused?
A) Nurses are mostly women, and sexual abusers are mostly men. B) Nurses have more time to work with the child than do other health professionals. C) Nurses identify with young children especially closely. D) Nurses tend to be trusted by children and are more likely to be confided in.
A child with slight irritability is diagnosed with a mild case of otitis media. The prescriber recommends acetaminophen. The parent comments to a nurse, "I expected my child to be started on an antibiotic."
The nurse's best response or responses are which of the following? (Select all that apply.) a. "Antibiotics are too expensive and toxic to be used in mild otitis media." b. "The child is not sick enough to warrant an antibiotic." c. "The provider does not believe antibiotics are ever indicated for otitis media." d. "Mild otitis media usually resolves without antibiotics." e. "Unnecessary antibiotics contribute to resistant organisms."