A nurse in a pediatric clinic is caring for a school-age child who has a perforated eardrum. The nurse suspects abuse. Which of the following actions should the nurse take?

Inform the parents that the findings must be reported to authorities.

Complete an incident report for risk management.

Interview the child about the suspected abuse with a parent present.

Avoid asking the child what caused the injury.

Answer and Explanation

The Correct Answer is A

Choice A reason: If a nurse suspects child abuse, they are legally required to report it to the appropriate authorities. Informing the parents that the findings must be reported is necessary to comply with mandatory reporting laws. This step ensures that the child receives the necessary protection and that the situation is investigated further by child protective services or law enforcement.

Choice B reason: Completing an incident report for risk management is an internal process used by healthcare facilities to document incidents that occur within the facility. While it is important to document the findings, this action alone does not fulfill the nurse's legal obligation to report suspected abuse to the authorities.

Choice C reason: Interviewing the child about the suspected abuse with a parent present may not be appropriate, especially if there is a possibility that the parent is the abuser. The presence of the parent could influence the child's responses and prevent them from speaking freely about the abuse. It is crucial to conduct the interview in a safe and supportive environment, often with a child protection professional or a social worker.

Choice D reason: Avoiding asking the child what caused the injury is not recommended in cases of suspected abuse. It is important for the nurse to gather as much information as possible about the cause of the injury. However, the nurse should approach the questioning in a sensitive and non-leading manner to avoid further traumatizing the child.

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Correct Answer is C

Explanation

Choice A reason: Hypoactive bowel sounds can indicate a variety of gastrointestinal issues, but they are not typically associated with haloperidol use. While it is important to monitor bowel sounds, it is not the priority in this context.

Choice B reason: Dry mouth is a common side effect of many medications, including haloperidol. While it can be uncomfortable for the client, it is not usually a serious concern and can be managed with hydration and other supportive measures.

Choice C reason: Constant opening and closing of the mouth, also known as tardive dyskinesia, is a serious side effect of haloperidol and other antipsychotic medications. This condition involves involuntary muscle movements and can be irreversible. It is crucial to report this finding to the provider immediately for assessment and potential adjustment of the medication regimen.

Choice D reason: Photosensitivity is not a common side effect of haloperidol. While it is important to monitor for any new or unusual symptoms, photosensitivity is not typically associated with this medication.

A. A systolic blood pressure decrease of 15 mm Hg after standing B. Hypersalivation C. Tinnitus D. A weight loss of 3.6 kg (8 lb) over a 6-month time period

Correct Answer is A

Explanation

Choice A reason: A decrease in systolic blood pressure of 15 mm Hg after standing could indicate orthostatic hypotension, which is a known adverse effect of amitriptyline. Orthostatic hypotension can lead to dizziness, lightheadedness, and falls, posing a significant risk to the patient's safety. Reporting this finding to the provider is crucial for assessing the need for dosage adjustments or alternative treatments.

Choice B reason: Hypersalivation is not a common adverse effect of amitriptyline. While dry mouth is a more typical side effect, hypersalivation would be unusual and might indicate an unrelated issue or an interaction with another medication.

Choice C reason: Tinnitus, or ringing in the ears, is not typically associated with amitriptyline use. While it can occur as a side effect of some medications, it is not commonly linked to this particular drug.

Choice D reason: A weight loss of 3.6 kg (8 lb) over a 6-month period is not generally considered an adverse effect of amitriptyline. Weight changes can occur with many medications, but significant weight loss should be evaluated in the context of the patient's overall health and other medications they may be taking.

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A nurse in a pediatric clinic is caring for a school-age child who has a perforated eardrum. The nurse suspects abuse. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is receiving haloperidol. Which of the following findings is the priority to report to the provider?

Correct Answer is C

Explanation

A nurse is collecting data from a client who is taking amitriptyline. Which of the following findings should the nurse report to the provider as an adverse effect of the medication?

Correct Answer is A

Explanation

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