Review H and P and nurse's notes.

What are the first four actions that the nurse should take?

Take the child's pulse

Place a cervical collar on the client

Look for any open wounds

Call child protective services

Determine if the child's airway is clear

Start a peripheral intravenous line

Answer and Explanation

Correct Answer : A,B,C,E

A)   Correct- Assessing the child's pulse helps determine their cardiac status and whether they have a detectable heartbeat. This information is essential for deciding the appropriate interventions.
B)   Correct- Placing a cervical collar is necessary if there is any suspicion of cervical spine injury due to the fall or submersion. This action helps stabilize the neck and prevent further damage to the spine.
C)   Correct- Checking for open wounds is important to assess for potential sources of bleeding or infection that may require immediate attention.
D)   Incorrect- While child safety is important, the immediate priority in this situation is assessing and stabilizing the child's medical condition. Child protective services may be involved later if there are concerns about the circumstances surrounding the incident.
E)   Correct- Assessing the airway is of utmost importance to ensure that the child can breathe. In cases of near-drowning, ensuring a clear airway is crucial for oxygenation.
F)   Incorrect- While establishing intravenous access may be important for certain interventions, it is not one of the immediate priorities in this situation. Ensuring the child's airway, breathing, and circulation take precedence.

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Correct Answer is C

Explanation

Delusions and loss of control can be distressing for the client and potentially disruptive to the unit environment. Moving the client to a quiet place helps create a calm and less stimulating environment, which can help reduce agitation and promote a sense of safety and security.

Using firmness and directing the client to sit for a while may escalate the situation and increase the client's distress. It is important to approach the client with empathy and provide a supportive environment rather than exerting control through firmness.

Suggesting the client take a walk or encouraging the client to use a punching bag may not be appropriate if the client is already displaying signs of agitation and losing control. These interventions may not address the underlying causes of the delusions and could potentially worsen the situation.

A. Insulin resistance B. Decreased epidermal turnover C. Pigmentation changes D. T-cell function decrease E. Polypharmacy F. Decreased subcutaneous padding

Correct Answer is ["B","D","F"]

Explanation

As people age, the turnover of skin cells decreases, resulting in slower wound healing. This can prolong the healing process and increase the risk of complications.

The immune system's function, including T-cell function, tends to decline with age.

T-cells play a crucial role in the immune response and wound healing. Decreased T-cell function can impair the body's ability to fight infection and promote efficient healing.

With aging, there is a natural loss of subcutaneous fat, which can affect wound healing. Subcutaneous fat provides padding and protection to the underlying tissues, and its reduction can increase the risk of tissue damage and delays in healing.

Insulin resistance, pigmentation changes, and polypharmacy are not directly age-related factors that impact wound healing. Insulin resistance is a condition related to impaired glucose metabolism and can affect wound healing in individuals with diabetes or other metabolic disorders, but it is not necessarily an age-related factor. Pigmentation changes and polypharmacy (the use of multiple medications) may be associated with aging but do not directly affect the physiological processes involved in wound healing.

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Review H and P and nurse's notes. What are the first four actions that the nurse should take?

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Naxlex Comprehensive Predictor Exams

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?

Correct Answer is C

Explanation

What age-related factors may factor into this client's wound healing? Select all that apply.

Correct Answer is ["B","D","F"]

Explanation

A client who has been taking allopurinol prophylactically comes into the clinic with reoccurring gout attack episodes in left ankle. The healthcare provider changes the prescription to febuxostat. Which instruction should the nurse include in the discharge teaching?

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider?

The nurse is caring for a client after a thoracentesis that drained 50 mL of clear fluid from the left lung. Which assessment finding should the nurse report to the healthcare provider immediately?

The mother of a 2-day-old infant girl expresses concern about a "flea bite" type rash on her daughter's body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer?

Review H and P and nurse's notes.

What are the first four actions that the nurse should take?