A nurse is talking privately with an adolescent who has disclosed that their facial fractures are the result of their punishment for coming home 1 hr after their curfew. Which of the following responses should the nurse make?
"I won't tell anyone else about this unless you say it's okay."
"Your parent was wrong to hit you for coming home late."
"I'm guessing your other parent did not do anything to stop this from happening."
"It is not your fault that this happened to you."
The Correct Answer is D
A. While it is important to maintain confidentiality, the nurse must follow mandatory reporting laws for suspected abuse, which may require informing appropriate authorities.
B. While it may be important to acknowledge the harm done, directly labeling the parent's behavior as "wrong" could potentially escalate the situation and may not be helpful in building rapport with the adolescent.
C. Making assumptions about the behavior of another parent can be seen as judgmental and may not be helpful in addressing the adolescent’s concerns or in facilitating a safe environment for disclosure.
D. This response provides reassurance to the adolescent that they are not responsible for the abuse and helps to create a nonjudgmental, supportive environment, allowing the adolescent to feel safe and heard.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Wiping from the outer corner of the eye to the inner canthus is incorrect because this can introduce bacteria from the outer part of the eye into the inner part, which could exacerbate the infection. The proper technique is to wipe from the inner canthus to the outer canthus to prevent contamination.
B. Cleaning the eye with a moist cloth is appropriate for conjunctivitis as it helps remove secretions and crusts that accumulate. Using a clean, moist cloth minimizes irritation to the eye.
C. Keeping the eye covered with a compress is not recommended unless directed by a provider. Compresses could increase irritation or harbor bacteria if not kept clean.
D. Applying eye ointment in the morning is not optimal because ointment should generally be applied at night to prevent blurred vision during the day. The nurse should advise applying it as prescribed by the healthcare provider.
Correct Answer is B
Explanation
A. Neck flexion when bending forward is not a typical indicator of scoliosis. Scoliosis is identified by abnormal curvature of the spine, not by the neck.
B. Uneven shoulders when standing erect are a key indicator of scoliosis. This asymmetry can be identified when the child bends forward at the waist, which is a standard test for scoliosis during a physical examination.
C. Toes that point inward when bending forward is not a sign of scoliosis. This could be indicative of a different musculoskeletal issue such as hip or leg alignment problems, but it is not related to scoliosis.
D. Knees that bow outward when standing erect indicate bow-leggedness (genu varum), not scoliosis. Scoliosis specifically affects the spine's curvature.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.