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 A
Explanation
A. Wooden building blocks are appropriate for an 18-month-old child, as they promote motor skills development, coordination, and creativity. At this age, children engage in parallel play and are developing their ability to manipulate objects.
B. Stringing beads requires more advanced fine motor skills that an 18-month-old child is not yet ready for. This activity is more appropriate for older children.
C. Colored paper and safety scissors could be a choking hazard for an 18-month-old child, and using scissors requires more advanced fine motor skills than most toddlers possess.
D. Alphabet flash cards are more suitable for older children, typically those who are 3 years and older, as they are better able to understand letters and begin to form associations with words.
Correct Answer is C
Explanation
A. Aspirin is contraindicated for children due to the risk of Reye's syndrome, a potentially fatal condition associated with aspirin use in children under the age of 18.
B. Administering acetaminophen at this frequency could result in overdose or liver damage, especially in children. Acetaminophen should be given at appropriate intervals (usually every 4–6 hours) as per the prescribed dosage.
C. Lowering the temperature of the room can help reduce the child’s fever without overcooling. A comfortable room temperature helps to prevent further heat retention and promotes the child's comfort.
D. An ice bath can cause shivering, which could raise the body temperature and cause additional harm. It is not recommended for fever reduction in children.
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