A child is accompanied to the clinic by the grandmother rather than by the parents. The grandmother says, "I am substituting for my daughter today because she is ill." The nurse would like to add information to the child's health history

How should the nurse proceed? 1. Wait until the parents bring the child to an appointment.
2. Understand that a grandmother is an authority on the child's life.
3. Plan to validate any information with the parents at the next visit.
4. Check the grandmother's accuracy by validating some data with the medical record.


3
Rationale 1: Waiting is not necessary if other steps are taken to validate information.
Rationale 2: The grandmother may know a lot about the child and the child's life but may not be the authority.
Rationale 3: Information gathered from the grandmother should be validated with the parent who is more of an expert on the child and the child's history.
Rationale 4: Just because the grandmother is accurate with some data is no assurance she will be accurate with all data.

Nursing

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The nurse is performing an initial assessment on the hospitalized client. The nurse is assessing the client's respiratory system. Rank the following steps in the correct sequence

Standard Text: Click and drag the options below to move them up or down. 1. The nurse percusses the client's thorax. 2. The nurse unties the client's gown to better visualize the client's thorax. 3. The nurse warms his stethoscope and listens to the client's lung sounds in each lung field. 4. The nurse gently palpates the client's thorax.

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The family of a patient being treated for a recent diagnosis of schizophrenia voices concerns to the nurse. They report the patient just told them that the pepper flakes on his potatoes were crawling bugs

What response by the nurse is most appropriate? a. "At this stage it is most important to hu-mor him and agree that you see them as well." b. "To reduce his stress, just throw out the food." c. "It is important to tell him that you do not see the bugs." d. "The best thing to do in this case is to confront him and let him know that he is mistaken."

Nursing

A client is admitted to a hospital for bronchial asthma and is allergic to certain smells. A nurse sprays freshener in the room. The client develops an allergy because of the freshener and his condition worsens

It is clear that the action of the nurse amounts to an offense. Under what category can the offense be classified? A) Negligence B) Tort C) Battery D) Malpractice

Nursing

A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client, "Do you receive special messages from certain sources, such as the television or radio?" Which potential symptom of this disorder is the nurse assessing?

A. Thought insertion B. Paranoia C. Magical thinking D. Delusions of reference

Nursing