During a home health visit, a school-age child who has muscular dystrophy confides in the nurse that he was struck by his parents. Which of the following actions should the nurse take first?
Report the incident to local authorities
Check the child for injuries
Refer the parent to a social service agency
Enroll the parent in anger management classes
The Correct Answer is B
Choice A reason: Reporting the incident to local authorities is an important action, but it is not the first priority. The nurse should first assess the child's physical condition and provide any necessary care.
Choice B reason: Checking the child for injuries is the first action the nurse should take, as the child may have sustained physical harm from the abuse. The nurse should document any findings and report them to the appropriate authorities.
Choice C reason: Referring the parent to a social service agency is a helpful action, but it is not the first priority. The nurse should first ensure the child's safety and well-being.
Choice D reason: Enrolling the parent in anger management classes is a potential intervention, but it is not the first priority. The nurse should first address the immediate needs of the child and the family.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Giving positive feedback to students who make appropriate choices is a good strategy to reinforce healthy eating, but it is not the first action that the nurse should take. The nurse should first assess the students' readiness to learn and their motivation to change their behavior.
Choice B reason: Helping students recognize the value of making healthy food choices is an important goal of the program, but it is not the first action that the nurse should take. The nurse should first determine the students' current knowledge, attitudes, and beliefs about healthy eating and tailor the program accordingly.
Choice C reason: Providing students with resources about making wise choices independently is a useful way to support their learning, but it is not the first action that the nurse should take. The nurse should first identify the barriers and facilitators that influence the students' food choices and address them in the program.
Choice D reason: Determining students' motivation to learn about healthy food choices is the first action that the nurse should take. This is based on the principle of learner-centered education, which states that the nurse should assess the learners' needs, interests, and readiness to learn before planning and implementing the program.
Correct Answer is B
Explanation
Choice A reason: The test does not monitor the progression of the disease, as it only detects the presence of antibodies to HIV, not the amount of virus or the damage to the immune system. Other tests, such as viral load and CD4 count, are used to monitor the progression of HIV infection and the response to treatment.
Choice B reason: The test measures antibodies to the virus, which are produced by the immune system in response to HIV infection. The test is used to screen for HIV infection and to confirm the diagnosis. A positive result indicates that the person has been exposed to HIV and has developed antibodies to the virus.
Choice C reason: The test results are not accurate 24 hours after exposure to the virus, as it takes time for the body to produce enough antibodies to be detected by the test. The window period, which is the time between exposure to HIV and a positive test result, varies from person to person, but it can range from 3 weeks to 3 months. Therefore, a negative result does not necessarily rule out HIV infection, and a repeat test may be needed after the window period.
Choice D reason: A positive result does not require initiating immunoglobulin administration, as immunoglobulin is not a treatment for HIV infection. Immunoglobulin is a preparation of antibodies that can provide temporary protection against some infections, but it does not affect HIV. A positive result requires further confirmation by a more specific test, such as the Western blot, and referral to a specialist for treatment and counseling.
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