A nurse is caring for a child and suspects the child has experienced physical maltreatment.Which of the following statements should the nurse make?

"It is not your fault that this happened."

"You should have told someone about this sooner."

"This should not have happened to you."

"I promise I won't tell anyone about this."

Answer and Explanation

The Correct Answer is C

Choice A reason:

While it's important to reassure the child, stating that it's not their fault is correct, the statement in choice C is a stronger affirmation of the inappropriateness of the situation.

Choice B reason:

This statement may inadvertently place blame on the child, which is not appropriate in this situation.

Choice C reason:

This statement communicates empathy and acknowledges that the child should not have experienced maltreatment.

Choice D reason:

While it's important to maintain the child's trust, the priority is to ensure the child's safety and report any suspected maltreatment to the appropriate authorities.

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Correct Answer is D

Explanation

Choice A reason:

A temperature of 37.7° C (99.9° F) is slightly elevated but not a cause for immediate concern after immunization. It can be a normal response.

Choice B reason:

Redness at the injection site is a common and expected reaction after immunization. It does not require immediate intervention.

Choice C reason:

Prolonged crying can occur after immunization, but it is not a priority over a potential allergic reaction indicated by hives.

Choice D reason:

Hives on the child's neck indicate a potential allergic reaction to the immunization. This is a priority finding and requires immediate attention from the nurse.

A. Improved feedings B. Restored surfactant C. Decreased CNS irritability D. Decreased excoriation

Correct Answer is C

Explanation

Choice A reason:

Improved feedings can be a positive sign, but it may not directly indicate the therapeutic effect of phenobarbital.

Choice B reason:

Restored surfactant is not directly related to the action of phenobarbital, which is used to manage symptoms of neonatal abstinence syndrome.

Choice C reason:

Phenobarbital is a medication that can help alleviate CNS irritability in infants with neonatal abstinence syndrome. Therefore, a decrease in CNS irritability indicates a therapeutic effect of the medication.

Choice D reason:

Decreased excoriation is not a primary effect of phenobarbital. This medication primarily addresses CNS symptoms associated with neonatal abstinence syndrome.

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A nurse is caring for a child and suspects the child has experienced physical maltreatment.Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a 6-month-old infant 20 min after administering a hepatitis B immunization. Which of the following findings is the nurse's priority?

Correct Answer is D

Explanation

A nurse is assisting with the care of a 1-month-old infant who has neonatal abstinence syndrome and is receiving phenobarbital. Which of the following findings indicates to the nurse that the medication has had a therapeutic effect?

Correct Answer is C

Explanation

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