Nelcx Assessment my world (Answered)
After listening to the parents report and assessing the ft padiiatic clients, the
nurse knows that which patient demonstrates signs of abuse that may
necessitate mandatory reporting
5 yrs old whose x- ray reveals 1 and new 2 healed humerus fractures after falling from
tree
What are signs of abuse that needs to be reported by nurse
1Shaken baby syndrome
2.Burns ( burns in shape of house hold items ) e.g. Iron
Spatula
Cigarettes
Or immersion in scalding liquid
3.repeated injuries in varied stages of healing
4 . Lapses of time between injury and time care is sought
5 inconsistency between injury and caregiver explanation
6 injury to genitalia
Shaken baby syndrome
a life-threatening condition that occurs when an infant is forcefully shaken back and
forth rupturing blood vessels in the brain and breaking neural connections
Sign and symptoms of shaken baby syndrome
Irritability
Lethargic
Poor feeding
Emesis
Seizures
If a nurse suspect an abuse what should she do
Report to state or provincial law
The charge nurse is responsible for making room assignments for multiple
patients. Which pair of clients assignment to share room is appropriate
Clients with bowel resection 1 day ago and clients with asthma exacerbatation
When making room assignments it is important to remember that
Active or suspected infection should not be paired.
The nurse for the patient with terminal disease who has advanced directives
supporting a do not resuscitate DNR code status. The patient stop breathing and
loses pluses. The patient son states , I changed my mind . Do whatever you can
to save him
Explain the patient wishes to the son
Advanced directives
Communicates a client's wishes regarding and end-of-life care should the client become
unable to do so. PSDA requires that all health care facilities ask if a patient has
advanced directives upon admission.
It allow family to follow patient wishes at the end of life when patient is unable to make
choices known
,The nuse is assessing a patient who is being treated for depression and suicidal
ideation. Which patient statement best indicate that the patient is not cure at risk
for suicide
I plan to attend my granddaughter graduation next month
What are risks factors of suicide
1 preexisting psychiatric disorders
2 hopelessness , impulsively
3 pervoius suicide attempts
Divorce
Elderly white men
Unemployed
Physical illness
Family history of suicide
Family discord
Access to firearms
Substance abuse
What are protective factors to prevent suicide
Social support
Family connectedness
Pregnancy
Parentshood
Religious and participation of religious activities
Imipramine
Which antidepressant matches the following statement: Can be used for betwetting in
children?;(
Tofranil)
Patient with suicide ideation and depression tell the nurse nurse she lost her
prescription of imipramine
Tofranil is tricyclics antidepressant. An over dose can be very fatal. Stockpiling
medication can sign of suicide plan
No harm contract
A spoken agreement between the physician and patient that if the patient feels like
hurting him or herself, he or she will notify the physician, nurse, or another family
member. But it does not guarantee safety
Patient with long term personal goal and family milestones are
Less likely to commit suicide
The nurse is reviewing the medical history of a patient who has sustained a right
tibia and fibula from fall. The nurse identified which findings as most likely to
hinder healing
Peripheral arterial disease
Tibia
Fibula
Normal BMI
18.5-24.9
Bone healing post fractures depend on
, Age
Nutritional status
Perfusion
Heavy alcohol use is associated with
Mal nutrition
Peripheral artery disease
Leads to impaired wound healing, tissue hypoxia, and decreased mobilization of white
blood cells to infected tissues; occurs at an earlier age and at a rate of two to four times
higher in people with diabetes.
Reduce blood flow due plague build up
Signs and symptoms of peripheral artery disease
Hair loss
Intermittent claudication
Cool dry shiny skin
Gangrene
Thick brittle nail
Ulcers
Stage 1 wound
First appears as a reddened area of skin that does not return to the normal color after
the pressure is remove
Intact
Non blanchable with localized redness
Stage Two wound
Shallow open ulcer
Red pink wound with no sloughing
Intact or ruptured blister . Is what stage
Stage 2
Stage 3 wound
Full thickness skin with possible visible subcutaneous fat
No exposed bone, Tendon or muscle
Stage 4 Wound
Full thickness skin loss
Exposed bone tendon or muscle
Unstageable wound
Full thickness skin loss
Ulcer base covered by slough and or Escher that needs removal to stage
The padiatric nurse plans a home visit for 2 years old who will be soon
discharged with home health care. Which condo presents most concern as safety
Hazard in the child's environment
House is heated by wound burning stove
House built in what year contains lead based painting
House built before 1978 have high probability of containing lead paint
Ingesting of lead by child will cause what
Neurological and motor impairment
The nurse is transporting a patient from the PACU to medical surgical floor unit
after surgery to repair penetration trauma to the chest. During transport the chest
After listening to the parents report and assessing the ft padiiatic clients, the
nurse knows that which patient demonstrates signs of abuse that may
necessitate mandatory reporting
5 yrs old whose x- ray reveals 1 and new 2 healed humerus fractures after falling from
tree
What are signs of abuse that needs to be reported by nurse
1Shaken baby syndrome
2.Burns ( burns in shape of house hold items ) e.g. Iron
Spatula
Cigarettes
Or immersion in scalding liquid
3.repeated injuries in varied stages of healing
4 . Lapses of time between injury and time care is sought
5 inconsistency between injury and caregiver explanation
6 injury to genitalia
Shaken baby syndrome
a life-threatening condition that occurs when an infant is forcefully shaken back and
forth rupturing blood vessels in the brain and breaking neural connections
Sign and symptoms of shaken baby syndrome
Irritability
Lethargic
Poor feeding
Emesis
Seizures
If a nurse suspect an abuse what should she do
Report to state or provincial law
The charge nurse is responsible for making room assignments for multiple
patients. Which pair of clients assignment to share room is appropriate
Clients with bowel resection 1 day ago and clients with asthma exacerbatation
When making room assignments it is important to remember that
Active or suspected infection should not be paired.
The nurse for the patient with terminal disease who has advanced directives
supporting a do not resuscitate DNR code status. The patient stop breathing and
loses pluses. The patient son states , I changed my mind . Do whatever you can
to save him
Explain the patient wishes to the son
Advanced directives
Communicates a client's wishes regarding and end-of-life care should the client become
unable to do so. PSDA requires that all health care facilities ask if a patient has
advanced directives upon admission.
It allow family to follow patient wishes at the end of life when patient is unable to make
choices known
,The nuse is assessing a patient who is being treated for depression and suicidal
ideation. Which patient statement best indicate that the patient is not cure at risk
for suicide
I plan to attend my granddaughter graduation next month
What are risks factors of suicide
1 preexisting psychiatric disorders
2 hopelessness , impulsively
3 pervoius suicide attempts
Divorce
Elderly white men
Unemployed
Physical illness
Family history of suicide
Family discord
Access to firearms
Substance abuse
What are protective factors to prevent suicide
Social support
Family connectedness
Pregnancy
Parentshood
Religious and participation of religious activities
Imipramine
Which antidepressant matches the following statement: Can be used for betwetting in
children?;(
Tofranil)
Patient with suicide ideation and depression tell the nurse nurse she lost her
prescription of imipramine
Tofranil is tricyclics antidepressant. An over dose can be very fatal. Stockpiling
medication can sign of suicide plan
No harm contract
A spoken agreement between the physician and patient that if the patient feels like
hurting him or herself, he or she will notify the physician, nurse, or another family
member. But it does not guarantee safety
Patient with long term personal goal and family milestones are
Less likely to commit suicide
The nurse is reviewing the medical history of a patient who has sustained a right
tibia and fibula from fall. The nurse identified which findings as most likely to
hinder healing
Peripheral arterial disease
Tibia
Fibula
Normal BMI
18.5-24.9
Bone healing post fractures depend on
, Age
Nutritional status
Perfusion
Heavy alcohol use is associated with
Mal nutrition
Peripheral artery disease
Leads to impaired wound healing, tissue hypoxia, and decreased mobilization of white
blood cells to infected tissues; occurs at an earlier age and at a rate of two to four times
higher in people with diabetes.
Reduce blood flow due plague build up
Signs and symptoms of peripheral artery disease
Hair loss
Intermittent claudication
Cool dry shiny skin
Gangrene
Thick brittle nail
Ulcers
Stage 1 wound
First appears as a reddened area of skin that does not return to the normal color after
the pressure is remove
Intact
Non blanchable with localized redness
Stage Two wound
Shallow open ulcer
Red pink wound with no sloughing
Intact or ruptured blister . Is what stage
Stage 2
Stage 3 wound
Full thickness skin with possible visible subcutaneous fat
No exposed bone, Tendon or muscle
Stage 4 Wound
Full thickness skin loss
Exposed bone tendon or muscle
Unstageable wound
Full thickness skin loss
Ulcer base covered by slough and or Escher that needs removal to stage
The padiatric nurse plans a home visit for 2 years old who will be soon
discharged with home health care. Which condo presents most concern as safety
Hazard in the child's environment
House is heated by wound burning stove
House built in what year contains lead based painting
House built before 1978 have high probability of containing lead paint
Ingesting of lead by child will cause what
Neurological and motor impairment
The nurse is transporting a patient from the PACU to medical surgical floor unit
after surgery to repair penetration trauma to the chest. During transport the chest
