The nurse is identifying tertiary prevention strategies to implement for this client.

Exhibits

Select the three actions the nurse should take.

Insist that the client explain the reason for their bruises.

Inform the client that their child is being abusive toward them.

Report suspected maltreatment to the appropriate agency.

Confront the client's child about the client's injuries.

Ask the client how the fracture occurred.

Conduct the interview with the client privately.

Answer and Explanation

Correct Answer : C,E,F

In a situation where maltreatment is suspected, it is important for the nurse to report their concerns to the appropriate agency. The nurse should also ask the client how the fracture occurred and conduct the interview with the client privately, without the presence of their child, to gather more information and assess the situation.

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Correct Answer is B

Explanation

To accurately assess the client's respirations, the nurse should observe the movements of the client's chest wall. This can be done by visually inspecting the rise and fall of the chest or by placing a hand on the client's chest to feel the movements. This allows the nurse to assess the depth, rhythm, and effort of the client's breathing. I

It is important to observe the client's respirations without informing them, as this may cause the client to alter their breathing pattern consciously.

Counting the client's respirations for a full minute (rather than 15 seconds) provides a more accurate measurement.

Placing the client in a supine position may not be necessary for assessing respirations, as it is primarily focused on observing the chest movements.

A. Choose a room that is well lit. B. Sit on the client's right side. C. Ask a few questions at a time. D. Exaggerate lip movement while speaking.

Correct Answer is A

Explanation

A nurse is assisting with the care of a client who has hearing loss and has questions regarding their medication. The nurse should choose a room that is well-lit, sit facing the client, speak clearly and slowly, and ask a few questions at a time. Exaggerating lip movement while speaking is not recommended as it can be difficult for the client to read lips accurately. Additionally, sitting on the client's right side may not make a significant difference in their ability to hear.

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The nurse is identifying tertiary prevention strategies to implement for this client. Exhibits Select the three actions the nurse should take.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is postoperative. Which of the following actions should the nurse take when collecting data about the client's respirations?

Correct Answer is B

Explanation

A nurse is assisting with the care of a client who has hearing loss and has questions regarding their medication. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about palliative care to a client who has cancer. Which of the following statements should the nurse make?

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A nurse is administering a client's morning oral medications. Which of the following actions should the nurse take?

A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation. The nurse notes that the client's vagina and vulva are a purplish color. The nurse should document this finding as which of the following?

The nurse is identifying tertiary prevention strategies to implement for this client.

Exhibits

Select the three actions the nurse should take.