The nurse is caring for a 12-year-old child who is on fall ...

[biggirl4568]

The nurse is caring for a 12-year-old child who is on fall precautions secondary to seizures. What interventions should be included in the child's care plan? (Select all that apply.)
 
  a. Place a call light and desired items within reach.
  b. Keep the bed in the highest position with the two side rails up.
  c. Turn off the lights and television at night.
  d. Keep personal belongings and clutter contained in one area of the floor.
  e. Have the child wear an appropriate-size gown and nonskid footwear.

Question 2

When checking the intravenous (IV) site on a child, the nurse should take which action?
 
  a. Look at the site.
  b. Ask the child if the site hurts.
  c. Look at the site while palpating the area.
  d. Take all the tape off, assess the site, and redress.

[bigcheese9]

Answer to Question 1

ANS: A, E
Prevention of falls requires alterations in the environment, including keeping call light and desired items within reach and having the child wear appropriate-size gowns and nonskid footwear. The bed should be in the lowest position possible with all the side rails up; at least a dim light should be left on at night; and personal belongings and clutter should not be on the floorthey should be in a cabinet.

Answer to Question 2

ANS: C
To appropriately check the intravenous (IV) site, the nurse should look at the site and palpate the area. The other options would not be adequate assessments of the site.

[biggirl4568]

Gracias!

[sarah_brady415]

Thanks for the timely response, appreciate it