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.
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Related Questions
Correct Answer is D
Explanation
A. Positioning the child on their back is not recommended, as it could increase the risk of aspiration. It's safer to hold the child in an upright position or slightly reclined, supporting the head and neck.
B. Adding medication to formula or food is not advisable, as the child may not ingest the full dose, and it might not be effective if the child doesn't finish the bottle.
C. While cold may help with taste, it could be difficult for a 1-year-old to handle ice, and it may not effectively improve medication administration.
D. Placing the medication along the side of the child's tongue helps prevent the gag reflex and encourages the child to swallow it more easily, ensuring proper administration.
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.
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