A 16-year-old is brought to the emergency room by her boyfriend with bruising around her eyes and neck.
When asked what happened, she states, "I walked into a door.”. What are the most appropriate interventions by the nurse?

Interview the client privately.

Maintain a calm, caring, professional demeanor.

Ask the teen if she feels safe.

Contact the police.

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale

Interviewing the client privately ensures confidentiality and allows for honest disclosure of the situation without fear of intimidation or manipulation by accompanying individuals. This approach is critical in identifying domestic abuse victims and initiating proper interventions.

Choice B rationale

A calm, caring, and professional demeanor fosters trust and reduces the client’s anxiety or fear. It ensures the nurse-patient relationship is non-threatening, encouraging the teen to open up about her experiences and facilitating accurate assessment and care.

Choice C rationale

Assessing whether the teen feels safe helps identify her immediate risks and the presence of a potential threat. Recognizing unsafe living conditions enables the nurse to involve appropriate protective and social services to ensure the client’s safety.

Choice D rationale

Contacting the police should be done only with the client’s consent unless mandated by law. Immediate police involvement without consent may jeopardize the client’s trust in the healthcare system and compromise her willingness to seek help in the future.

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Correct Answer is B

Explanation

Choice A rationale

Teaching the child how to use an inhaler supports self-management but does not address developmental readiness for independent inhaler use. At five years old, children often require supervision due to incomplete cognitive and motor development.

Choice B rationale

Providing information to the caregiver about child development stages clarifies expectations for independent inhaler use. This knowledge aligns with the protective factor of ensuring developmentally appropriate interventions for pediatric asthma management.

Choice C rationale

Community resources offer support but do not directly relate to the child's ability to use the inhaler without supervision. While beneficial, this option does not prioritize the developmental readiness aspect of pediatric care.

Choice D rationale

Referring the caregiver to an asthma educator focuses on skill-building and education but overlooks the specific developmental readiness of the child. Direct caregiver education on developmental milestones is more impactful in this context. .

A. Massage the fundus until it firms. B. Notify the healthcare provider. C. Document the fundal height and consistency. D. Administer Oxytocin V as per MD orders.

Correct Answer is A

Explanation

Choice A rationale

Massaging the fundus is the first-line intervention when the fundus is soft and spongy, indicating uterine atony. Massage stimulates uterine contractions, reducing postpartum bleeding and restoring uterine tone, which is crucial to prevent hemorrhage.

Choice B rationale

Notifying the healthcare provider is necessary if initial interventions fail to address uterine atony. However, immediate action such as massaging the fundus should be taken first to minimize bleeding risks and stabilize the client.

Choice C rationale

Documenting fundal height and consistency is important but not an immediate intervention. Recording observations without addressing the atony fails to prevent potential complications like postpartum hemorrhage, which requires prompt and active management.

Choice D rationale

Administering Oxytocin as per MD orders aids uterine contraction but is not the first intervention. Massaging the fundus provides immediate mechanical stimulation to contract the uterus, a vital step before pharmacological measures are considered.

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A 16-year-old is brought to the emergency room by her boyfriend with bruising around her eyes and neck.When asked what happened, she states, "I walked into a door.”. What are the most appropriate interventions by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute pediatric unit is assessing a 5-year-old child following an asthma event.The child's caregiver expects the child to use an inhaler without supervision.The nurse can apply which of the following interventions as protective factors for the child?

Correct Answer is B

Explanation

A nurse is assessing the fundus of a postpartum client one day after delivery and notes that the fundus is soft and spongy.Which is the first nursing intervention to perform?

Correct Answer is A

Explanation

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A 16-year-old is brought to the emergency room by her boyfriend with bruising around her eyes and neck.
When asked what happened, she states, "I walked into a door.”. What are the most appropriate interventions by the nurse?