A school nurse is assessing a child and notes various bruises on the child's body that are unexplained. Which of the following actions should the school nurse take?

Arrange for a meeting with the child's guardians tomorrow.

Notify the president of the school board.

Ask the child's peers about the bruises

Report the findings to child protective services.

Answer and Explanation

The Correct Answer is D

Rationale:

A. Arrange for a meeting with the child's guardians tomorrow: Meeting with the guardians may be appropriate later, but initially, the nurse must follow mandatory reporting laws. Waiting to meet could delay protection for the child and place them at further risk.

B. Notify the president of the school board: Reporting to school administration does not replace legal obligations to report suspected child abuse. The school board president is not the appropriate authority for immediate child protection.

C. Ask the child's peers about the bruises: Questioning peers is inappropriate and could violate privacy or compromise the investigation. The nurse should not attempt to investigate the situation personally.

D. Report the findings to child protective services: As a mandated reporter, the nurse is legally required to report any suspected child abuse immediately to child protective services. This action ensures the child’s safety and initiates an official investigation.

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Correct Answer is D

Explanation

Rationale:

A. "Store oxygen cylinders on their side.": Oxygen cylinders should always be stored upright and secured to prevent tipping, rolling, or falling, which could damage the valve and create a fire hazard. Storing cylinders on their side increases the risk of accidents and is unsafe in the home setting.

B. "Use two-prong electrical outlets in the room where oxygen is used.": Electrical safety requires that outlets and devices used near oxygen be in good condition and free of sparks. The number of prongs is not the key concern; rather, all electrical equipment should be properly grounded and well-maintained to prevent ignition in an oxygen-rich environment.

C. "You can adjust the flow of your oxygen as needed.": Oxygen flow should only be adjusted according to the provider’s prescription. Changing the flow without guidance can result in hypoxia if decreased or oxygen toxicity if increased, making this statement unsafe and incorrect.

D. "Notify your power company that oxygen is used in the home.": Informing the power company is an important safety measure because home oxygen use increases fire risk. Utility companies can provide guidance on electrical safety, and emergency responders will be aware of the presence of oxygen in case of power outages or accidents.

A. Confusion B. Acetone breath C. Polydipsia D. Hot, dry skin

Correct Answer is A

Explanation

Rationale:

A. Confusion: Confusion is an early neurological manifestation of hypoglycemia caused by insufficient glucose supply to the brain. Clients may also experience irritability, shakiness, or difficulty concentrating, which are key indicators to assess for after insulin administration.

B. Acetone breath: Acetone or fruity breath odor is associated with diabetic ketoacidosis (DKA), a hyperglycemic emergency, not hypoglycemia. This occurs due to ketone buildup when insulin is deficient, which is opposite of low blood glucose.

C. Polydipsia: Excessive thirst is a symptom of hyperglycemia, not hypoglycemia. It occurs when elevated glucose levels cause osmotic diuresis, leading to dehydration and thirst, and is not expected shortly after insulin lispro administration.

D. Hot, dry skin: Hot, dry skin is typically associated with hyperglycemia or fever. In hypoglycemia, the client often exhibits cool, clammy skin due to sympathetic nervous system activation and sweating, making this finding inconsistent with low blood glucose.

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A school nurse is assessing a child and notes various bruises on the child's body that are unexplained. Which of the following actions should the school nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a prescription for oxygen administration at home. Which of the following statements should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is assessing a client who has type 1 diabetes mellitus and was administered insulin lispro 1 hr ago. Which of the following manifestations indicates that the client might be experiencing hypoglycemia?

Correct Answer is A

Explanation

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