The nurse is caring for a 4-year-old on the pediatric unit who ...

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The nurse is caring for a 4-year-old on the pediatric unit who was in an automobile accident. Her mother was killed in the accident, and the father is telling the child that her mother is dead.
 
  The nurse expects the child to respond with which of the following? 1. The child will cry and be depressed.
   2. The child will react with anger and may be violent.
   3. The child will ask for her toys and ignore what the father is saying.
   4. The child will ask if mommy will cook her favorite meal when she wakes up.

Question 2

The nurse is preparing discharge instructions for a client with a surgical wound. Which instruction is most important for the client to follow?
 
  1. Adjust your diet so it contains more fruits and vegetables.
   2. Apply lubricating lotion to the edges of the wound.
   3. Notify your physician if you notice edema, heat, or tenderness at the wound site.
   4. Thoroughly irrigate the wound with hydrogen peroxide.

[dpost18]

Answer to Question 1

4. The child will ask if mommy will cook her favorite meal when she wakes up.

Rationale:
The child of 4 generally thinks of death as being sleep, and with that level of understanding, it would be reasonable to ask for her mother to make her a meal upon waking. The nurse will want to explain to the father that this is a normal reaction of a child of this age. The child will not appear to show grief or become angry because the mother is sleeping. Neither would the child ignore what her father tells her about her mother.

Answer to Question 2

3. Notify your physician if you notice edema, heat, or tenderness at the wound site.

Rationale:
A client being discharged with an open surgical wound has to be instructed on the detection of infection since the skin is the first line of defense. Signs such as edema, heat, and tenderness would indicate a local infection. Increasing fruits and vegetables would increase vitamin C, which helps with wound healing, but more protein would be the best choice. Applying lubricating lotion to the edges of a wound would impede the healing process. Irrigating with hydrogen peroxide would break down good granulating tissue, so this also would not increase healing.