Sim: Ann Rails

The nurse reviews the information received in report.

(Maybe wrong: Sim has a glitch) Safety: injury prevention Physiological: Comfort Physiological: Mobility Physiological: Pain Physiological: Tissue integrity

Which of the following statements should the nurse include in the documentation? (Select all that apply.)

Client appears afraid of their partner Client staes their partner abused them When asked about the injury, the client's partner stated, "They fell from a step ladder." The client's parter stood next to them to keep them from speaking" Client has a 3cm purple bruise on right cheek and 3.4 cm yellow/green bruise on left forehead."

Which of the following actions should the nurse take? (Select all that apply.)

Ensure the client's environment is safe Use therapeutic communication to further assess the client Document client's statements using their exact wording Contact local law enforement Have security remove client's partner from the hospital

Which of the following revisions should the nurse add? (Select all that apply.)

Psychosocial: Stress and Coping Psychosocial: Mood and Affect Health Promotion: Self Care Psychosocial: Spirituality

Which of the following assessment findings requires immediate follow-up? (Select all that apply.)

Pulse Blood Pressure Client's affect Pain Muscle cramping Bruises

Which of the following actions should the nurse plan to help alleviate the client's pain? (Select all that apply.)

Review the client's MAR Assist the client in changing positions Apply ice to the affected area