The nurse reviews the health record of a 2-year-old child and ...

[Davideckstein7]

The nurse reviews the health record of a 2-year-old child and notes that the physician has documented that the results of a Mantoux test have indicated an area of induration measuring 5 mm. The nurse would interpret these results as:
 
  1. Positive
  2. Negative
  3. Inconclusive
  4. Definitive, requiring a repeat test

Question 2

An older female client with delirium becomes agitated and confused at night. The nurse's most important strategy for this is to do which of the following?
 
  1. Turn off the television and radio, and use a nightlight.
  2. Keep soft lighting and the television on during the night.
  3. Change the client's room to one nearer the nurses' station.
  4. Play soft instrumental music all night, and do not turn down the lights.

[kilada]

Answer to Question 1

2

Rationale: Induration measuring 10 mm or greater is considered to be a positive result in children younger than 4 years. A reaction of 5 mm or greater is considered to be a positive result for the highest risk groups.

Answer to Question 2

1

Rationale: A nightlight is needed for client safety to reduce the risk of falls if the client should get out of bed unattended. It is important to reduce environmental stimulation and provide a consistent daily routine for a disoriented client. Noise levels, including radio and television, may add to the confusion and disorientation. Moving the client to a room near the nurses' station is not the first action.

[Davideckstein7]

TYSM

[bigcheese9]

Excellent