A nurse is caring for a client who is receiving penicillin G via intermittent IV piggyback.

Which of the following actions should the nurse take?

The correct answer is C. Explain to the child what will happen when the abuse is reported.

This is because the nurse should provide honest and accurate information to the child about the reporting process and the possible outcomes, such as legal actions, investigations, or removal from the home.

This can help the child feel more prepared and less anxious about what will happen next. The nurse should also reassure the child that the abuse is not their fault and that they did the right thing by telling someone.

Choice A is wrong because reassuring the child that no one will be told about the abuse is unethical and illegal.

The nurse has a mandatory duty to report any suspected or confirmed cases of child abuse to the appropriate authorities, such as child protective services or law enforcement. Keeping the abuse a secret can also endanger the child’s safety and well-being, as well as prevent them from receiving the necessary medical and psychological care.

Choice B is wrong because ensuring that multiple nurses are present for the physical examination can increase the child’s fear, embarrassment, or discomfort.

The nurse should minimize the number of people involved in the examination and only include those who are essential for providing care or collecting evidence. The nurse should also explain to the child what will be done during the examination and obtain their consent before proceeding.

Choice D is wrong because using leading statements to obtain information from the child can influence their responses and affect the validity of their testimony.

The nurse should use open-ended questions and avoid suggesting or implying any details about the abuse. The nurse should also document the child’s statements verbatim and avoid interpreting or paraphrasing them.

Choice A reason

Weight loss is not the correct answer: Weight loss is not a common side effect of simvastatin. In fact, weight loss is generally not associated with statin use. If the client experiences significant, unintentional weight loss, it may indicate another underlying issue that should be reported to the provider.

Choice B reason:

Muscle weakness is the correct answer. The nurse should instruct the client to monitor and report any muscle weakness to the healthcare provider when taking simvastatin. Simvastatin is a statin medication used to lower cholesterol levels in the blood. While statins are generally well-tolerated, they can occasionally cause muscle-related side effects, including muscle weakness or pain.

Rhabdomyolysis, a severe condition characterized by the breakdown of muscle fibres, is a rare but serious side effect of statin use. Muscle weakness may be an early sign of this condition. Therefore, if the client experiences any unexplained or persistent muscle weakness while taking simvastatin, it should be reported to the healthcare provider immediately.

Choice C reason

Fever is not the correct answer: Fever is not a common side effect of simvastatin. If the client develops a fever while taking simvastatin, it is more likely to be related to another condition and should be reported to the provider for further evaluation.

Choice D reason:

Edema is the correct answer: Edema (swelling) is not a common side effect of simvastatin. If the client experiences significant edema, especially in the extremities, it may indicate another underlying issue that should be reported to the provider.