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. Facial edema is not typically associated with a urinary tract infection (UTI). Edema may be seen in other conditions, such as nephrotic syndrome.
B. An increased temperature (fever) is a common manifestation of a UTI. The body responds to the infection with an elevated temperature as part of the immune response.
C. Moist mucus membranes are a sign of adequate hydration and are not specifically related to a UTI.
D. Muscle twitching is not a common sign of a UTI. It could be related to electrolyte imbalances or neurological issues, but it is not typical for UTIs.
Correct Answer is D
Explanation
A. The HbA1c test does not check for ketones in urine. Ketone testing is separate and used to assess for diabetic ketoacidosis or inadequate insulin use, not for monitoring long-term blood glucose control.
B. While the HbA1c test involves hemoglobin, it does not measure the total amount of hemoglobin in the blood. Instead, it reflects the percentage of hemoglobin that has glucose attached to it over a period of time.
C. The HbA1c test does not measure oxygen levels in the blood. It specifically measures the average blood glucose level over a 2-3 month period by assessing the percentage of glucose-bound hemoglobin.
D. The HbA1c test provides an indication of long-term blood glucose control, reflecting the average blood glucose levels over the past 2-3 months. It is a crucial tool for managing diabetes and monitoring the effectiveness of treatment plans.
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