The nurse should be aware of signs of physical, sexual, and emotional abuse and comply with state or provincial mandatory
reporting. Signs of abuse may include:
• Shaken baby syndrome (ie, irritability or lethargy, poor feeding, emesis, seizures)
• Burns in the shape of household items (eg, iron, spatula), from cigarettes, or from immersion in scalding liquid
• Repeated injuries in varied stages of healing (eg, bruises, burns, fractures) (Option 4)
• Injuries to genitalia
• Lapsed time between the injury and the time when care is sought
• Inconsistency between the injury and the caregiver's explanation of the injury (eg, client's developmental
age, mechanism of injury)
(Options 1, 2, and 3) Toddlers and young children are prone to many accidental injuries (eg, aspiration or poisoning from
foreign objects in the mouth, climbs onto and falls from furniture, pulling of objects from the table). The injuries and
caregivers' explanations are reasonable for these clients. Prior to discharge, the nurse should instruct caregivers on child
safety measures within the home to prevent future injury.
Educational objective:
The nurse should be aware of signs of physical, sexual, and emotional abuse, including repeated injuries in varied stages of
healing, shaken baby syndrome, and injuries to genitalia. Suspicion of abuse necessitates mandatory reporting according to
state or provincial laws.
Paranoia is the belief that others desire or are attempting to persecute or harm (eg, spy on, cheat, follow, poison) the
individual. Clients with paranoid delusions often are suspicious of other people, including health care professionals, and may
refuse treatment or aid out of fear of being harmed.
Management of paranoia focuses on building trust with and grounding the client in reality. When the client believes food
has been poisoned, the nurse can build trust and promote adequate nutrition by offering unopened, individually packaged
food (Option 4).
Educational objective:
Nurses caring for clients who have paranoid delusions must work to build a trusting relationship and ground the client while
ensuring basic needs are met (eg, nutritional intake). When clients believe food is poisoned, the nurse should offer unopened,
individually packaged food to promote adequate intake without reinforcing delusions.
Steps for indwelling urinary catheter insertion for the male client include:
• Perform hand hygiene and open sterile catheterization kit (Option 3).
• Apply sterile gloves and place sterile fenestrated drape with opening centered over penis (Option 2).
• Maintaining sterility of gloves, arrange remaining kit supplies on sterile field. Remove protective covering
from catheter, lubricate catheter tip, and pour antiseptic solution over cotton balls or swab sticks.
• Firmly grasp penis with nondominant hand, retracting foreskin if present. Nondominant hand is now
considered contaminated and remains in this position for duration of procedure (Option 6).
• Use dominant (sterile) hand to cleanse in a circular motion from the meatus to the glans with antiseptic
solution using cotton balls or swab sticks. Use new cotton ball/swab stick with each swipe (Option 4).
• Use dominant hand to pick up catheter and insert it until urine return is visualized in catheter tubing (Option 5).
• Advance to bifurcation of catheter tubing. Hold in place and inflate balloon (Option 1). Urine return in catheter
tubing may be from urethra and does not indicate that balloon tip is fully inside bladder. Because male urethra
varies in length, balloon should not be inflated until catheter is fully advanced.
Educational objective:
To insert an indwelling urinary catheter in a male client, perform hand hygiene, apply sterile gloves and place sterile
fenestrated drape, arrange supplies on sterile field, grasp penis with nondominant hand, cleanse from meatus to glans using
dominant hand, insert catheter until urine return is visualized, advance catheter to tubing bifurcation, and inflate balloon.
Allowing family to be present during resuscitative efforts and invasive procedures can help the family process
and cope with the client's condition, alleviate fears and anxiety, and facilitate the grieving process if the expected outcome is
poor. The nurse should permit the client's spouse to enter the room and provide a location to observe (out of the care team's
way) and another nurse should explain the treatment measures that are occurring (Option 1).
Educational objective:
During resuscitative efforts and invasive procedures, the nurse should allow family members to be present if they desire.
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,Allowing family members to be present helps with coping, alleviates fear and anxiety, and facilitates the grieving process in
the case of a poor outcome.
Central venous catheters (CVCs) are used in the treatment of clients who require long-term IV access or are prescribed
hypertonic solutions (eg, total parenteral nutrition) or vesicant medications. CVCs can serve as a portal of entry for
bacteria, which increases the risk of developing serious bloodstream infections. Nurses caring for clients with CVCs should
report any new or worsening signs of infection (eg, fever, chills, erythema at the CVC site) to the health care provider
because central line–related bloodstream infections (CRBSIs) require prompt treatment to prevent possible sepsis.
In response to a possible CRBSI, the CVC should be removed as soon as possible to prevent continued exposure to the
infection source. Blood cultures should be obtained before initiating antibiotic therapy, as antibiotics may contaminate the
sample and prevent identification of the infectious organism (Option 4).
Educational objective:
When caring for a client with signs of a central line–related bloodstream infection, the nurse should obtain blood cultures and
remove the device, if possible, before beginning antibiotic therapy. Other nursing interventions (eg, symptom management,
documentation) should be done after initiating treatment of the infection.
When making room assignments, it is important to remember that a client with an active or suspected infection should
not be paired with a client who has a fresh surgical wound or is immunocompromised. A client having an asthma
exacerbation does not have an infection and is not at risk for spreading infection to a client who had recent bowel resection
surgery (Option 3).
Educational objective:
When preparing room assignments, the nurse should not place a client who has a fresh surgical wound or is
immunocompromised in a room with a client who has an active or suspected infection.
Advance directives outline the client's choices for medical care (eg, cardiopulmonary resuscitation [CPR], mechanical
ventilation) ahead of time. This allows the family and care team to follow the client's wishes at the end of life, when the
client may be unable to make choices known. Clients can sign a do not resuscitate (DNR) directive instructing that CPR
and other life-saving measures be withheld. With an advance directive in place, the client's wishes are followed, even if
they conflict with the wishes of loved ones (Option 3). This is different from a medical power of attorney (health care
proxy) in which the client designates a person to make decisions on their behalf.
Educational objective:
Advance directives outline the client's choices for medical care at the end of life, including resuscitation status. Client's
wishes for medical care are honored over the wishes of family members.
Suicide risk & protective factors
• Psychiatric disorders, prior suicide attempts
• Hopelessness
• Never married, divorced, separated
• Living alone
• Elderly white man
Risk factors
• Unemployed or unskilled
• Physical illness
• Family history of suicide, family discord
• Access to firearms
• Substance abuse, impulsivity
• Social support/family connectedness
• Pregnancy
Protective factors
• Parenthood
• Religion & participation in religious activities
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,Clients receiving treatment for depression and suicidal ideation must be carefully monitored for indications of increasing
suicidal intent. During a client interview, the nurse should assess:
• Access to psychiatric medications
• Availability of help during a crisis (eg, counselor, family)
• Future goals and plans
• Home and work environment risks
• Overall affect and level of energy
• Possible access to weapons
Clients who articulate long-term personal goals and family milestones are less likely to commit suicide (Option 2).
Educational objective:
Nursing care for clients with suicidal ideation includes assessment of home and work environments, access to psychiatric
medications, overall affect, availability of help, access to weapons, and energy level. Clients who articulate long-term
personal goals and family milestones are less likely to commit suicide.
The nurse is preparing to administer acetaminophen to a 4-year-old client weighing 43 lb. Based on the prescription, what is
the volume of medication in milliliters (mL) that the child should receive with each dose? Click on the exhibit button for
more information. Record your answer using a whole number.
The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula fracture from a fall. The nurse
identifies which finding as most likely to hinder healing?
Bone healing depends on multiple factors, including nutrition, adequate circulation, and age. A client with peripheral
arterial disease has decreased perfusion to the extremities due to atherosclerotic changes in the arteries. Without adequate
perfusion, the bone is not supplied with the oxygen and nutrients required for healing (Option 4).
Educational objective:
Bone healing after fracture depends on multiple factors, including age, nutritional status, and perfusion. A client with
peripheral arterial disease is at risk for impaired bone healing.
Based on the nursing assessment progress notes, what is the correct staging of the client's pressure injury? Click on the
exhibit button for additional information.
Pressure injuries are staged from 1 to 4 to classify the degree of tissue damage and determine the most appropriate and
effective wound treatments.
• Stage 1: Intact skin with nonblanchable redness
• Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the dermis or epidermis;
the wound bed is red or pink and may be shiny or dry
• Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon, muscle, or bone; tunneling may be
present
• Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or eschar (scabbing, dead tissue) may
be present; undermining and tunneling may be present
• Pressure injuries are described as "unstageable" if the base is covered by necrotic tissue or eschar
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, Educational objective:
Stage 2 pressure injuries have partial-thickness skin loss (abrasion, blister, or shallow crater). The skin blisters or forms an
open sore, and the area around the sore may be red and irritated.
A client with type 1 diabetes has prescriptions for NPH insulin and regular insulin. At 7:30 AM, the client's blood glucose
level is 322 mg/dL (17.9 mmol/L), and the client's breakfast tray has arrived. What action should the nurse take? Click on
the exhibit button for additional information.
Intermediate-acting insulins (NPH) can be safely mixed with short-acting (regular) and rapid-acting (lispro, aspart)
insulins in one syringe (Option 4). Due to the client's blood glucose reading (322 mg/dL [17.9 mmol/L]), 12 units of regular
insulin are needed along with the scheduled 25 units of NPH insulin.
Prepare the mixed dose:
1. Inject 25 units of air into the NPH insulin vial without inverting the vial or passing the needle into the solution.
2. Inject 12 units of air into the regular insulin vial and withdraw the dose, leaving no air bubbles.
3. Draw 25 units of NPH insulin, totaling 37 units in one syringe. Any overdraw of NPH into the syringe will
necessitate wasting the entire quantity.
Most long-acting insulins (eg, glargine, detemir) are not suitable for mixing and typically are packaged in prefilled
injection pens.
Educational objective:
NPH insulin and regular insulin may be safely mixed and administered as a single injection. Regular insulin should be drawn
into the syringe before intermediate-acting insulin to avoid cross-contaminating multidose vials (mnemonic – RN: Regular
before NPH).
The pediatric nurse plans a home visit for a 2-year-old who will soon be discharged with home health care. Which condition
presents the most concern as a safety hazard in the child's home environment?
The safety of the home environment should be assessed prior to discharge of pediatric clients, especially those with
illnesses requiring continuing health care services in the home. The nurse can prioritize safety risks according to Maslow's
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