A nurse in an urgent care clinic is caring for a school-age child who has injuries resulting from physical maltreatment. Which of the following actions should the nurse take first?

Ensure the child's safety.

Tell the child they are not at fault.

Document the location of the child’s injuries

Notify local law enforcement.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Ensuring the child's safety is the top priority. If the child is in immediate danger, steps must be taken to protect them.

Choice B reason:

While providing emotional support to the child is important, ensuring their physical safety takes precedence.

Choice C reason:

Documenting injuries is important for a comprehensive assessment and for legal purposes, but it should follow ensuring the child's immediate safety.

Choice D reason:

Notifying law enforcement may be necessary, but ensuring the child's immediate safety comes first.

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Correct Answer is C

Explanation

Choice A reason:

Increased alertness may be a sign of improved glucose levels, but it is not as direct an indicator as a blood glucose measurement.

Choice B reason:

Diaphoresis is a symptom of low blood glucose levels and indicates the need for intervention rather than effectiveness of therapy.

Choice C reason:

A blood glucose level of 50 mg/dL is within the normal range and indicates that the glucagon therapy has been effective in raising blood glucose levels.

Choice D reason:

The presence of urine ketones indicates that the body is using fats for energy, which may occur in the absence of adequate glucose. This is not an indicator of the effectiveness of glucagon therapy.

A. High protein, high calorie B. High fat, low protein C. Moderate protein, low calorie D. Low carbohydrate, high fat

Correct Answer is A

Explanation

Choice A reason:

Children with cystic fibrosis often have increased calorie needs due to the extra energy required to breathe and the malabsorption of nutrients. A diet that is high in both protein and calories

helps meet these increased energy needs.

Choice B reason:

While a higher fat intake may be beneficial for some children with cystic fibrosis, it should not be at the expense of protein intake, which is also crucial for growth and development.

Choice C reason:

A diet that is low in both protein and calories would not be appropriate for a child with cystic fibrosis, as it may not provide sufficient energy and nutrients to support growth and

development.

Choice D reason:

A diet that is low in carbohydrates and high in fat is not typically recommended for children with cystic fibrosis. They need a balanced diet that includes a variety of macronutrients to meet their

increased energy needs.

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A nurse in an urgent care clinic is caring for a school-age child who has injuries resulting from physical maltreatment. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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