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 C

Explanation

Choice A rationale

Diaphragms need to be refitted periodically as changes in weight, pregnancy, or aging can affect their fit. This ensures that the device continues to function effectively by providing a proper seal over the cervix, reducing the risk of unintended pregnancy. Therefore, the statement about the diaphragm always being the correct size is inaccurate as it does not consider these physiological factors.

Choice B rationale

Diaphragms are not recommended for use during menstruation because the menstrual flow can compromise their efficacy and hygiene. Additionally, the risk of toxic shock syndrome may increase if the device is used during menstruation. This is a critical point to emphasize for the safe and effective use of diaphragms in contraception.

Choice C rationale

Leaving the diaphragm in place for six hours after intercourse ensures that sperm are effectively trapped and neutralized by the spermicide used with the device. This is essential for preventing fertilization and optimizing contraceptive effectiveness. The timing is critical to allow the spermicide to work while the diaphragm acts as a physical barrier.

Choice D rationale

Leaving the diaphragm in for extended periods beyond six hours is not recommended due to the increased risk of infection and toxic shock syndrome. The device should be removed within a safe timeframe to maintain hygiene and reduce health risks, making the statement about leaving it for a day or two incorrect.

A. Perform a sharp hand clap near the infant. B. Place a finger at the base of the newborn's toes. C. Hold the newborn vertically allowing one foot to touch the table surface. D. Turn the newborn's head quickly to one side.

Correct Answer is A

Explanation

Choice A rationale

Performing a sharp hand clap near the infant activates the Moro reflex, a startle response present at birth that integrates by around six months of age. The reflex involves symmetric extension and abduction of the arms followed by flexion, demonstrating proper neurological function.

Choice B rationale

Placing a finger at the base of the newborn's toes elicits the plantar grasp reflex, not the Moro reflex. This reflex involves flexion of the toes when pressure is applied to the sole and is unrelated to startling the infant.

Choice C rationale

Holding the newborn vertically allowing one foot to touch the table surface elicits the stepping reflex, not the Moro reflex. This reflex involves simulated walking movements and is unrelated to assessing startle responses.

Choice D rationale

Turning the newborn's head quickly to one side elicits the tonic neck reflex (fencing reflex) rather than the Moro reflex. This reflex involves extension of the limbs on the side the head is turned and flexion on the opposite side. .

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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

After receiving instruction on the use of a diaphragm for contraception, which statement by the client indicates that they have understood the teaching?

Correct Answer is C

Explanation

A nurse is caring for a newborn and assessing newborn reflexes.To elicit the Moro reflex, the nurse should take which of the following actions?

Correct Answer is A

Explanation

A nurse is teaching a newborn's parent to care for the umbilical cord stump.Which of the following instructions should the nurse include?

Which assessment findings would alert the nurse to an infant or child in heart failure?

Which statement made by a pregnant patient indicates teaching was effective related to an elevated alpha fetoprotein (AFP) level?

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The nurse is caring for a laboring client who presents with ruptured membranes, frequent contractions, and bloody show.Which intervention should be performed first?

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

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?