Strategy: Answers are implementations.

Determine the outcome of each

answer choice. Is it desired?
(1) no specific exercise program is necessary, children of this age in good health are
naturally active
(2) limits a childs interaction with the outside world, should be used judiciously
(3) correctsafety is fundamental issue with this age group; they are exploratory in
their play
(4) unnecessary, children learn by observing and by participating
137. A two-year-old is admitted to the pediatric unit with numerous bruises,
a fractured left humerus, and several lacerations with unexplained origin.
The nurse would identify which of the following as a priority nursing action?
1. Report the findings to the Child Protection Agency.
2. Share this information only with other health care professionals.
3 Document this information in the chart.
4. Share the information with the Pediatric Social Worker.
Strategy: All answers are implementations. Determine the outcome of each
answer choice. Is it desired?
(1) correctany suspicion of child abuse should be reported to the Child Protection
Agency
(2) does not provide or plan for protection of the child
(3) does not provide or plan for protection of the child
(4) does not provide or plan for protection of the child
138. A 72-year-old patient is admitted to the hospital for treatment of a
fractured femur. The patients wife tells the nurse that he has become very
hard of hearing. The nurse might expect the patient to exhibit which of the
following characteristics?
1.
2.
3.
4.

The
The
The
The

patient prefers to be left alone.

patient appears suspicious of strangers.
patient communicates best in writing.
patients speech is difficult to understand.

Strategy: All answers are assessments. Determine how each assessment

relates to this situation.
(1) unrelated to hearing deficit
(2) correctsuspiciousness results from interference with communication
(3) writing may be difficult for patient, depends on intellectual capacity
(4) diminished hearing late in life does not cause speech difficulties
139. The nurse is caring for a client with type I diabetes mellitus (IDDM).
The client is receiving nasal oxygen at 4L/min. The student nurse reports
that the client has pulled out his nasogastric tube and is picking at this bed
covers. The clients BP is 150/90 and pulse is 90. Which of the following
actions by the nurse is MOST appropriate?
1.
2.
3.
4.

Obtain a pulse oximetry reading.

Apply soft wrist restraints.
Reorient the client to person and place.
Determine the clients blood glucose level.