Question

XVIII. Mandi tells the nurse that her boyfriend is a 21-year-old that she met in an online chat room. After they go out to eat, he complains that she is fat and sometimes punches her in the stomach so that she will throw up her dinner and remember to eat less the next time. To gather data related to the frequency of abuse by Mandi's boyfriend what action should the nurse take first?

1. Instruct the client that there is no point in denying the pattern of abuse because of the varying color of bruises.

2. Determine if the client has ever tried to break up with her boyfriend and how she attempted to end the relationship

3. Ask the client about her boyfriend's use of any illegal drugs or frequency of alcohol abuse since they have been dating

4. Provide a calendar to mark the dates when any violent or abusive behavior by her boyfriend occurred.

XIX. When talking to Mandi about her boyfriend Mandi starts to scratch her neck and says "oh no this happens when I get really stressed". What should the nurse plan to find in response to Mandi's itching? 19. Purpura 20. Hirsutism 21. Urticaria 22. Pustules XX. The nurse observes raised pink wheals on Mandi's neck. How should the nurse respond to this observation?

1. ask if the client has been stung by an insect recently

2. explain that antibiotics will need to be prescribed

3. Apply a warm compress directly over the wheals

4. Offer assurance that this is a temporary response

XXI. The nurse prepares to administer Benadryl 12.5 mg PO, the tablet is supplied in a 25 mg dose, how many tablets should the nurse give? XXII. The nurse teaches Mandi about Benadryl what information should the nurse include? Select all that apply.

1. Benadryl blocks the effect of histamine response to reduce itching

2. Benadryl products contain aspirin so observe for signs of bleeding

3. This medication may cause drowsiness

4. Blurred vision or loss of balance are potentially serious side effects of this medication

5. This medication may cause an increase in secretions and moisten mucous membranes

XXIII. Which strategy should the nurse use to document the extent of the physical injuries?

1. Complete the abuse assessment screen

2. Prepare a detailed injury map

3. Include X-rays on the client’s record

4. Use the numeric Braden scale

XXIV. How should the nurse document the information obtained when charting Mandi's abuse assessment?

1. Delete any expletives the client used when describing the abuser

2. Quote the client's responses to the questions as verbatim as possible

3. summarize the abusive events without directly quoting the client

4. Refrain from including information that might identify the alleged abuser

Answer 1

XVIII. provide a calender to mark dates when any violent or abusive behavior occured. it helps to assess frequency of abusive. neither three provide explanation of frequency of abuse by her boy friend. varying color of bruises doesnot explain about frequency of abuse. consumption of alcohol and illegal drugs doenot explain frequency of abuse and asking about their ending relationship will not provide explanation.

XIX she has urticaria. Purpura is small red or purple colored spot under the skin. Hirsutism is presence of coarse hair in face, body like male. Pustules is blister that has Pus. when insect bites an individual, raised papule with urticaria present.

XX. Offer assurence that this is temporary response. urticaria is results from stress. The client made a statement that she has itching when she gets stressed. this causes histamine is released from the body due to stress. neither atibiotic warm compress will not provide any releif.

XXI: the nurse should give half of the available tablet . the 25mg tablet divided equally and to be giveto patient.

XXII. 1.bendryl blocks effect of histamine and reduced itching. 3.it causes drowsiness

blurred vision and loss of balance are common side effects of bendryl. not potential sideeffects of the medication. it doesnot aspirin

XXIII document extent of physical injuries which result from abuse. . prepare detailed injury map is used for record extent and location of physical injury. complete abuse assessment screen is screen assessment inn some insitution. some institution has no body map in their record. braden scale is used to predicting pressure ulcer. Xray is used for diagnosing fracture.

XXIV: Quote the client's responses to questions as verbatim as possible. this is abuse assessment form, should be documented as said by patient. this is the legal one. neitherthree would be used for documentation