m m m m m m
etail Solutions and Resource for the test)
m m m m m m
AgingmProcess
NewbornmAssessment:mExpectedmFindings
● NormalmAssessmentmFindingsmformHead:mShouldmbem2-
3mcmmlargermthanmchest.
● Anteriormfontanel mshouldmbempalpatedmandmapproximatelym5mcmm
onmaveragemandmdiamondmshaped.
● Posteriormfontanel mismsmallermandmtriangle-
shaped.mShouldmbemsoftmandmflat.mMoldingmofmsuturesmismnormal.
PsychosocialmIntegrity
Crisis mIntervention
SexualmAssault:mPriority mIntervention
● Providemamprivatemenvironmentmandmlimitmpersonnelmwhomexaminemthemclient.
● Assess mclientmemotions mandmprovidemsupport
● Assess,mtreat,mandmdocumentmallminjuries
● Usemamnonmjudgementalmandmempathetic mapproach
Abuse/Neglect
PsychosocialmIssues mofmInfants,mChildren,mandmAdolescents:mCaringmformamChildmWho
,Reports mSexualmAbuse
● Removemthemchildmfrommthemsituation
● Mandatorymreportingmformallmhealthmcaremworkers;mtheremaremcivilma
ndmcriminalmpenaltiesmformnotmreporting
● Assessmformunusual mbruisingmonmABD,mbackmandmbuttocks
,Sensory/PerceptualmAlterations
EffectivemCommunication:mRespondingmtomamClientmWhomIsmObesemandmIs mCryingmPsy
chotic mDisorders:mCaringmFormamClientmWhomIs mExperiencingmDelusions
● Ask mthemclientmdirectly maboutmhallucinations.mThemnursemshouldmnotmarguemormor
agreemwithmthemclient’s mviewmofmthemsituation.
● Domnotmarguemwithmamclient’s mdelusions,mbutmfocus monmthemclient’s mfeelings m
andmpossibly moffermreasonablemexplanations.
● Assess mthemclientmformparanoidmdelusions,mwhichmcanmincreasemthemrisk mfor
violencemagainstmothers.
BasicmCaremandmComfort
Elimination
Postpartum mPhysiologicalmAdaptations:mInterventions mtomPromotemVoiding
● Assistmwithmfrequentmurination
● Providemnoninvasivemmeasures mtompromotemurination
● Perform mbladdermscan
NutritionmandmOralmHydration
Burns:mSupportingmNutritionalmRequirements
● Clientmwithmamlargemburnminjury mwillmbeminmamhypermetabolic mstatemandm
may mexceedm5,000mcalories/day
● Increasemproteinmintakemtompreventmtissuembreakdownmandmpromotemhealing
● Enteralmormtotalmparenteralmtherapy mis moftenmnecessary mMedica
tions mformDepressivemDisorders:mFoodmandmMedicationmInteraction
● MAOIs-mavoidmfoods mcontainingmtyraminem(meats,mcheeses,malcohol)
● SSRIm&mSNRI-mavoidmalcohol
● Tricyclic-mdomnotmadministermwithmMAOIs mormSt.mJohn's mWart
, RenalmDisorders:mTeachingmamClientmWhomHas mChronic mKidney mDisease
● StrictmI&Os