A young adult client is brought to the emergency department reporting a headache. The client has bruises around the face and on the upper arms. The nurse suspects the client is the victim of physical abuse. In which order should the nurse implement these interventions? (Arrange the nursing actions with the highest priority first, on top, and lowest priority last, on bottom.)
Provide a safety plan to prevent further violence.
Inspect head for trauma.
Evaluate range of motion of all joints.
Perform a neurological exam.
The Correct Answer is B,D,C,A
- Inspect head for trauma. Head injuries can be life-threatening, so the nurse must first assess for signs of skull fractures, concussions, or intracranial bleeding that could explain the headache.
- Perform a neurological exam. If head trauma is suspected, a neurological exam is essential to assess for altered mental status, coordination deficits, or signs of increased intracranial pressure.
- Evaluate range of motion of all joints. After ruling out life-threatening conditions, the nurse should assess for musculoskeletal injuries, fractures, or soft tissue damage from physical abuse.
- Provide a safety plan to prevent further violence. Once the client is medically stable, the nurse should provide resources, assess risk for further harm, and develop a safety plan to prevent future abuse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["3.8"]
Explanation
3.8 mL per dose
Calculation:
- Convert 35 pounds to kilograms: 35÷2.2=15.9kg
- Determine the correct dosage:
- 15 to 23 kg → 45 mg BID
- Calculate the volume to administer: 45mg÷12mg/mL=3.75mL
- Round to the nearest tenth:
- 3.75 ≈ 3.8 mL
Thus, the nurse should administer 3.8 mL per dose.
Correct Answer is A
Explanation
A. Thyroxine (T4). Congenital hypothyroidism is diagnosed by measuring low levels of thyroxine (T4) and elevated thyroid-stimulating hormone (TSH). Infants with hypothyroidism have delayed metabolism, poor growth, and developmental delays. Reporting low T4 levels is critical for early treatment with levothyroxine to prevent intellectual disability and growth impairment.
B. Growth hormone (GH) levels. While GH is important for growth, it is not the primary diagnostic test for congenital hypothyroidism. GH deficiency is a separate endocrine disorder.
C. Follicle-stimulating hormone (FSH) levels. FSH is involved in reproductive development and is not relevant for diagnosing hypothyroidism in an infant.
D. Luteinizing hormone (LH) levels. LH plays a role in pubertal development and reproductive function, but it is not used to diagnose congenital hypothyroidism.
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