(50 Q study with rationale)
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Terms in this set (50)
,An 8-year-old child is seen in the ANS: C
clinic with a green vaginal
discharge. Which action is most A green vaginal discharge is indicative of
important for the nurse to gonorrhea, a sexually transmitted disease.
implement? Because the child is 8 years old, the nurse
should suspect child abuse and report the
A.Assess the child's blood incident to the proper authorities (C). (A) is
pressure. usually not related to infection. (B and D) are
B.Counsel the child to wear cotton helpful in preventing bladder infections, but a
underwear. green vaginal discharge is not a symptom of a
C.Report as suspected child abuse. bladder infection.
D.Determine if the child takes
bubble baths.
,A 22-year-old client is admitted to ANS: A
the psychiatric unit from the
medical unit following a suicide Encouraging the client to focus on his or her
attempt with an overdose of strengths (A) helps the client become aware of
diazepam (Valium). When positive qualities, assists in improving self-
developing the nursing care plan image, and aids in coping with past and present
for this client, which intervention situations. Although nursing actions should
would be most important for the assist the client in decreasing self-defacing
nurse to include? comments (B) and informing the client of (C),
these interventions are not priorities at this time.
A.Assist client to focus on personal (D) is not as important as assisting the client to
strengths. overcome the depression, which resulted in the
B.Set limits on self-defacing overdose, and asking "why" is not therapeutic.
comments.
C.Remind the client of daily
activities in the milieu.
, D.Assist the client to identify why
he or she was self-destructive.