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 A

Explanation

Choice A rationale

Horizontal eustachian tubes in children with cleft palate increase the risk of otitis media due to impaired drainage and ventilation. Surgical closure of the palate helps restore anatomical structure, reducing the incidence of middle ear infections and associated complications.

Choice B rationale

Small external ear structure is not anatomically linked to hydrocephalus, and diuretics are unrelated to managing this condition. Hydrocephalus stems from cerebrospinal fluid accumulation, not external ear anatomy, making this option inaccurate.

Choice C rationale

A large tongue may lead to airway obstruction but is not linked to otitis externa. Ear drops manage external ear infections but do not address anatomical changes associated with cleft palate, which impacts the eustachian tubes and middle ear.

Choice D rationale

An opening in the lip does not directly cause pneumonia. Pneumonia is primarily a respiratory condition influenced by infections, not lip anatomy. Corticosteroids are not standard interventions for pneumonia related to cleft palate complications.

A. Low-grade fever for three days. B. Slight yellow vaginal discharge. C. Frothy, white vaginal discharge. D. Decrease in urinary frequency.

Correct Answer is B

Explanation

B. Slight yellow vaginal discharge is correct.This is a classic symptom of gonorrhea in females. Gonorrhea often causes mucopurulent cervicitis, leading to a mild yellow vaginal discharge. It’s one of the most common signs, especially in sexually active adolescents.

Incorrect options:

A. Low-grade fever for three days:
Not a typical early symptom of gonorrhea. Fever may occur in severe or disseminated gonococcal infections, but it's uncommon as an initial presentation.
C. Frothy, white vaginal discharge:
This is more characteristic of trichomoniasis, another STI, caused by Trichomonas vaginalis. The discharge is typically frothy, greenish-yellow, and accompanied by a foul odor.
D. Decrease in urinary frequency:
Not associated with gonorrhea. Gonorrhea can cause increased urinary frequency and urgency if the urethra is involved, but a decrease is not typical.

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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

Identify a complication resulting from a cleft palate, the anatomical changes that lead to the complication, and the priority interventions for care.

Correct Answer is A

Explanation

Which assessment finding would the nurse expect to find in a sexually active adolescent female concerned that she has contracted gonorrhea?

Correct Answer is B

Explanation

Incorrect options:

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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?