Author Question: Security was contacted to remove a handgun from the pants pocket of a client who had been admitted ... (Read 73 times)

beccaep · **on:** Jun 25, 2018

Security was contacted to remove a handgun from the pants pocket of a client who had been admitted with wounds sustained in a fight. Which nursing diagnosis should the nurse include in this client's care plan?

A) Risk for Violence to Others
B) Risk for Loneliness
C) Risk for Situational Low Self-Esteem
D) Fear

Question 2

The nurse is instructing a pregnant adolescent client on how the baby's condition is evaluated during labor. Which client statement indicates appropriate understanding of the information presented?

A) During labor, the nurse will verify that my contractions are strong but not too close together.
B) During labor, the nurse will look at the color and amount of bloody show that I have.
C) During labor, the nurse will assess the baby's heart rate with an electronic fetal monitor.
D) During labor, the nurse will check my cervix by doing a pelvic exam every two hours.

pallen55 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Answer: A

The client had a handgun in a pants pocket that could have been used on others in the client's environment. The diagnosis of Risk for Violence to Others is appropriate for this client. There is not enough information to determine whether or not the client has a self-esteem disturbance, is afraid, or is at risk for loneliness.

Answer to Question 2

Answer: C

During labor, the nurse will assess the baby's heart rate with an electronic fetal monitor. This is the statement the client should make to prove that education was successful. Although cervical exams are performed on a regular basis, this does not assess fetal status. The client was asked specifically about assessing fetal status in labor. Although bloody show is monitored, doing so does not assess fetal status. Although contraction strength is palpated abdominally, this does not assessment fetal status.