An unconscious client is brought to the emergency department by ambulance for trauma treatment
The client is wearing a cocktail dress, high heels, and a wig, but on close inspection has facial and
body hair consistent with being male.
Further inspection determines that the client is male. Several
staff laugh and make remarks about transvestism as they stabilize the client. The most appropriate
action for the nurse is to say
a. "Your focus should be treatment, not ridicule.".
b. "Each client deserves our respect.".
c. "Your behavior constitutes client abuse.".
d. "Grow up, you have seen this before.".
B
The scenario is an example of a stigmatization of a medically ill client. The nurse should advocate
for the client in this situation. Option B is a simple, straightforward reminder of the need to respect
the dignity of each individual. Remembering that clients who are unconscious may still be able to
hear should cause the nurse to attempt to immediately put an end to the negative comments being
made without being argumentative or accusative.
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The nurse is preparing to admit a 7-year-old child with ataxic cerebral palsy. What clinical manifestations of ataxic cerebral palsy should the nurse expect to observe? (Select all that apply.)
a. Wide-based gait b. Rapid, repetitive movements performed poorly c. Slow, twisting movements of the trunk or extremities d. Hypertonicity with poor control of posture, balance, and coordinated motion e. Disintegration of movements of the upper extremities when the child reaches for objects
Sandra Brown is a nurse in a pediatric clinic. Recently Sandra helped care for Tiffany Peters, a 6-month-old who had developed a high fever and had a seizure following her third diphtheria, tetanus,
and pertussis (DTaP) vaccine injection. Because of her experience, Sandra knew that after Tiffany had been assessed and treated, she was required to: 1. Assure Tiffany's mother that this problem was probably an isolated case and that she should not hesitate to bring Tiffany back for her booster immunizations at 15 months. 2. Obtain the lot number of the DTaP vaccine that Tiffany had been given from her record and return all vaccine from the same lot to the manufacturer. 3. Report the incident to the Vaccine Adverse Events Reporting System. 4. Talk with the nurse who had given Tiffany's injection to be sure she knew there had been a problem.
The nurse is ready to enter into the process of planning care for a client with paranoid schizo-phrenia. Planning will include:
1. Determining needs and problems 2. Analyzing effectiveness of care 3. Establishing realistic outcome criteria 4. Identifying priorities of care