The nurse is making a home visit to a Korean family whose ...

[Ebrown]

The nurse is making a home visit to a Korean family whose daughter gave birth 6 weeks earlier. She finds the daughter in bed with a severe headache.
 
  The daughter's father is holding her hand and is pressing different parts of the hand and lower arm. The mother explains that the father is trying to cure the headache by using pressure points. The nurse's best response would be to a. Tell the father to stop and give the daughter Tylenol.
  b. Ask the mother and/or father to explain the procedure.
  c. Explain to the father that what he is doing will not work.
  d. Let the father finish and then give the daughter Tylenol.

Question 2

A patient presents to the emergency department following a motor vehicle crash and suffers from a right femur fracture. The leg is stabilized in a full leg cast.
 
  Otherwise, the patient has no other major injuries, is in good health, and complains only of moderate discomfort. What is the most pertinent nursing diagnosis to be included in the plan of care based on the assessment data provided? a. Posttrauma syndrome
  b. Constipation
  c. Urinary retention
  d. Acute pain

[zogaridan]

Answer to Question 1

B
The nurse should not judge the patient's/family's beliefs and values about health. The nurse needs to create a comfortable, nonthreatening environment and to learn as much as possible about the patient's culture and values that influence his or her health care practices. Tylenol may not be an acceptable alternative for this family. Criticizing the family's beliefs and practices will only create a barrier to care.

Answer to Question 2

D
Based on the assessment data provided, the only supportive evidence for one of the diagnosis options is Complains of moderate discomfort, which would support Acute pain. No supportive evidence is provided for any of the other diagnoses. The patient may indeed develop signs or symptoms of the other problems, but supportive data are presently lacking in the provided information.