A 5-year-old girl is brought to the clinic for symptoms of a urinary tract infection (UTI). The nurse's assessment reveals bruises in the child's genital and rectal areas. The nurse's first priority with this client is:
Teach the mother about symptoms of UTI
Report suspected sexual abuse to protective services
Interview mother for child’s health history
Obtain a urine sample to confirm UTI
The Correct Answer is B
A. Teach the mother about symptoms of UTI is not the nurse's first priority. While educating the mother about UTIs is important, the presence of bruises in the genital and rectal areas raises immediate concern for potential sexual abuse, which requires immediate action to ensure the child's safety.
B. Report suspected sexual abuse to protective services is the nurse's first priority. Any signs of physical trauma or injury in areas typically covered by clothing, such as the genital and rectal areas, must be reported immediately. The nurse is a mandated reporter and is legally required to report any suspected abuse. Ensuring the safety of the child is paramount, and protective services will investigate the situation and take appropriate steps.
C. Interview mother for child’s health history may be necessary later, but at this moment, the immediate concern is the possibility of sexual abuse. The nurse should report the findings to the appropriate authorities before discussing the situation further with the mother.
D. Obtain a urine sample to confirm UTI is important for diagnosing the UTI but does not address the immediate concern regarding possible abuse. The child’s safety and well-being must be prioritized, and reporting the possible abuse is more urgent than confirming the UTI at this point.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I think you need more medication. I will be right back." While medication is an important aspect of managing Alzheimer's disease, this response dismisses the patient's feelings and does not address the emotional content of the statement. The goal is to engage with the patient in a compassionate way, not to assume the medication is the solution.
B. "Your wife passed away last year. Who's your date?" This response may be truthful, but it could be very distressing for the patient. Alzheimer's disease often causes memory loss and confusion, so correcting the patient in this blunt manner may cause unnecessary emotional distress or frustration.
C. "Today is (today's date). Tell me about the other dances you've been to." This is the most appropriate response. It gently redirects the patient to reality by providing the correct date, but it also shows empathy and invites the patient to share pleasant memories. This approach validates the patient's emotions and encourages conversation, which is beneficial for maintaining dignity and engaging the patient in meaningful dialogue.
D. "You're confused. Today is not Valentine's Day." This response may make the patient feel invalidated or upset. Alzheimer's disease often causes confusion and disorientation, so harshly correcting the patient can lead to increased agitation and emotional distress.
Correct Answer is D
Explanation
A. Denial is a common defense mechanism in patients with Alzheimer's disease. Individuals may refuse to accept the reality of their cognitive decline, which can lead them to deny their condition or deny symptoms, such as memory loss.
B. Confabulation refers to the unintentional creation of false memories to fill in memory gaps. It is a defense mechanism often seen in Alzheimer's patients as they attempt to make sense of their experiences or answer questions when they do not remember the correct information.
C. Perseveration is the repetition of a word, phrase, or action. Patients with Alzheimer's may exhibit perseveration when they become fixated on a thought or action and repeat it persistently, which is often a coping mechanism for confusion or disorientation.
D. Rationalization is a defense mechanism where individuals justify or explain their behaviors in a seemingly logical way to avoid feelings of guilt or discomfort. While it can be seen in many types of psychological distress, rationalization is not typically a behavior associated with Alzheimer's disease. Instead, Alzheimer's patients are more likely to demonstrate denial, confabulation, or perseveration, as they struggle with cognitive decline and memory loss.
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