(Detail Solutions and Resource for the test)
Aging Process
Newborn Assessment: Expected Findings
● Normal Assessment Findings for Head: Should be 2-3 cm larger than
chest.
● Anterior fontanel should be palpated and approximately 5 cm on
average and diamond shaped.
● Posterior yfontanel yis ysmaller yand ytriangle-shaped. yShould ybe ysoft
yand yflat. yMolding yof ysutures yis ynormal.
Psychosocial yIntegrity
Crisis yIntervention
Sexual yAssault: yPriority yIntervention
● Provide ya yprivate yenvironment yand ylimit ypersonnel ywho yexamine ythe
yclient.
● Assess yclient yemotions yand yprovide ysupport
● Assess, ytreat, yand ydocument yall yinjuries
● Use ya ynon yjudgemental yand yempathetic yapproach
Abuse/Neglect
Psychosocial yIssues yof yInfants, yChildren, yand yAdolescents: yCaring yfor ya yChild
yWho yReports ySexual yAbuse
● Remove ythe ychild yfrom ythe ysituation
● Mandatory yreporting yfor yall yhealth ycare yworkers; ythere yare ycivil
yand ycriminal ypenalties yfor ynot yreporting
● Assess yfor yunusual ybruising yon yABD, yback yand ybuttocks
,Sensory/Perceptual y Alterations
Effective yCommunication: yResponding yto ya yClient yWho yIs yObese yand yIs yCrying
yPsychotic yDisorders: yCaring yFor ya yClient yWho yIs yExperiencing yDelusions
● Ask ythe yclient ydirectly yabout yhallucinations. yThe ynurse yshould ynot
yargue yor yor yagree ywith ythe yclient’s yview yof ythe ysituation.
● Do ynot yargue ywith ya yclient’s ydelusions, ybut yfocus yon ythe yclient’s
yfeelings yand ypossibly yoffer yreasonable yexplanations.
● Assess ythe yclient yfor yparanoid ydelusions, ywhich ycan yincrease ythe yrisk yfor
violence yagainst yothers.
Basic yCare yand yComfort
Elimination
Postpartum yPhysiological yAdaptations: yInterventions yto yPromote yVoiding
● Assist ywith yfrequent yurination
● Provide ynoninvasive ymeasures yto ypromote yurination
● Perform ybladder yscan
Nutrition yand yOral yHydration
Burns: ySupporting yNutritional yRequirements
● Client ywith ya ylarge yburn yinjury ywill ybe yin ya yhypermetabolic ystate
yand ymay yexceed y5,000 ycalories/day
● Increase yprotein yintake yto yprevent ytissue ybreakdown yand ypromote
yhealing
● Enteral yor ytotal yparenteral ytherapy yis yoften ynecessary
yMedications yfor yDepressive yDisorders: yFood yand yMedication
yInteraction
● MAOIs- yavoid yfoods ycontaining ytyramine y(meats, ycheeses, yalcohol)
● SSRI y& ySNRI- yavoid yalcohol
● Tricyclic- ydo ynot yadminister ywith yMAOIs yor ySt. yJohn's
yWart yRenal yDisorders: yTeaching ya yClient yWho yHas yChronic
yKidney yDisease
, ● Strict yI&Os