The nurse should be aware of signs of physical, sexual, and emotional abuse and comply with state or provincial mandatory

reporting. Signs of abuse may include:

• Shaken baby syndrome (ie, irritability or lethargy, poor feeding, emesis, seizures)

• Burns in the shape of household items (eg, iron, spatula), from cigarettes, or from immersion in scalding liquid

• Repeated injuries in varied stages of healing (eg, bruises, burns, fractures) (Option 4)

• Injuries to genitalia

• Lapsed time between the injury and the time when care is sought

• Inconsistency between the injury and the caregiver's explanation of the injury (eg, client's developmental age,

mechanism of injury)

(Options 1, 2, and 3) Toddlers and young children are prone to many accidental injuries (eg, aspiration or poisoning from

foreign objects in the mouth, climbs onto and falls from furniture, pulling of objects from the table). The injuries and

caregivers' explanations are reasonable for these clients. Prior to discharge, the nurse should instruct caregivers on child

safety measures within the home to prevent future injury.

Educational objective:

The nurse should be aware of signs of physical, sexual, and emotional abuse, including repeated injuries in varied stages of

healing, shaken baby syndrome, and injuries to genitalia. Suspicion of abuse necessitates mandatory reporting according to

state or provincial laws.

Paranoia is the belief that others desire or are attempting to persecute or harm (eg, spy on, cheat, follow, poison) the

individual. Clients with paranoid delusions often are suspicious of other people, including health care professionals, and may

refuse treatment or aid out of fear of being harmed.

Management of paranoia focuses on building trust with and grounding the client in reality. When the client believes food

has been poisoned, the nurse can build trust and promote adequate nutrition by offering unopened, individually packaged

food (Option 4).

Educational objective:

Nurses caring for clients who have paranoid delusions must work to build a trusting relationship and ground the client while

ensuring basic needs are met (eg, nutritional intake). When clients believe food is poisoned, the nurse should offer unopened,

individually packaged food to promote adequate intake without reinforcing delusions.

Steps for indwelling urinary catheter insertion for the male client include:

• Perform hand hygiene and open sterile catheterization kit (Option 3).

• Apply sterile gloves and place sterile fenestrated drape with opening centered over penis (Option 2).

• Maintaining sterility of gloves, arrange remaining kit supplies on sterile field. Remove protective covering from

catheter, lubricate catheter tip, and pour antiseptic solution over cotton balls or swab sticks.

• Firmly grasp penis with nondominant hand, retracting foreskin if present. Nondominant hand is now

considered contaminated and remains in this position for duration of procedure (Option 6).

• Use dominant (sterile) hand to cleanse in a circular motion from the meatus to the glans with antiseptic solution

using cotton balls or swab sticks. Use new cotton ball/swab stick with each swipe (Option 4).

• Use dominant hand to pick up catheter and insert it until urine return is visualized in catheter tubing (Option 5).

• Advance to bifurcation of catheter tubing. Hold in place and inflate balloon (Option 1). Urine return in catheter

tubing may be from urethra and does not indicate that balloon tip is fully inside bladder. Because male urethra

varies in length, balloon should not be inflated until catheter is fully advanced.

Educational objective:

To insert an indwelling urinary catheter in a male client, perform hand hygiene, apply sterile gloves and place sterile

fenestrated drape, arrange supplies on sterile field, grasp penis with nondominant hand, cleanse from meatus to glans using

dominant hand, insert catheter until urine return is visualized, advance catheter to tubing bifurcation, and inflate balloon.

Allowing family to be present during resuscitative efforts and invasive procedures can help the family process

and cope with the client's condition, alleviate fears and anxiety, and facilitate the grieving process if the expected outcome is

poor. The nurse should permit the client's spouse to enter the room and provide a location to observe (out of the care team's

way) and another nurse should explain the treatment measures that are occurring (Option 1).

Educational objective:

During resuscitative efforts and invasive procedures, the nurse should allow family members to be present if they desi