A nurse is caring for a child who received an initial dose of antibiotics 20 minutes ago.Which of the following findings is the priority to report to the provider?
Increased pulse.
Wheezing.
Maculopapular rash.
Headache.
The Correct Answer is B
Choice A rationale
An increased pulse can be a sign of many conditions and is not as immediately alarming in the context of a potential allergic reaction as respiratory symptoms.
Choice B rationale
Wheezing is the priority finding because it indicates airway constriction, a hallmark of anaphylaxis, which is a severe and potentially life-threatening allergic reaction requiring immediate treatment.
Choice C rationale
A maculopapular rash can be a sign of an allergic reaction, but it is not immediately life-threatening like airway constriction. It should be reported but is not the priority.
Choice D rationale
A headache can be a symptom of many non-emergent conditions and does not indicate an immediate risk to the child's airway or circulation. It requires attention but is not the priority in this context.
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Correct Answer is C
Explanation
Choice A rationale
While acknowledging that hitting a child is wrong is important, the nurse must use therapeutic communication techniques to support the adolescent. Directly stating that the parent was wrong may cause the adolescent to feel defensive or ashamed, and it may not be the most effective way to provide emotional support. The goal is to create a safe and trusting environment where the adolescent feels comfortable discussing their experiences. The nurse should focus on providing empathetic and non-judgmental support to help the adolescent process their feelings and access appropriate resources.
Choice B rationale
Telling the adolescent not to disclose their abuse to anyone else unless it is okay by them is inappropriate and goes against the principles of safeguarding and mandatory reporting. Healthcare professionals have a duty to protect vulnerable individuals and report suspected abuse to the appropriate authorities. This response could inadvertently discourage the adolescent from seeking help or disclosing further information. It is essential to follow protocols for reporting abuse while ensuring the adolescent feels supported and understands that the nurse is taking steps to ensure their safety.
Choice C rationale
Reassuring the adolescent that the abuse is not their fault is an important aspect of providing emotional support and validation. Victims of abuse often struggle with feelings of guilt, shame, and self-blame. By explicitly stating that it is not their fault, the nurse helps to alleviate these feelings and reinforces that the adolescent is not to blame for the abusive behavior. This response aligns with principles of trauma-informed care and helps to build a trusting relationship between the nurse and the adolescent, which is crucial for their emotional healing.
Choice D rationale
Implying that the other parent did nothing to stop the abuse can lead to further emotional distress for the adolescent and may cause feelings of betrayal or abandonment. This response may not provide the necessary support or validation the adolescent needs in that moment. The nurse should focus on addressing the immediate emotional needs of the adolescent and providing reassurance and support. Discussions about the roles of other family members should be handled delicately and may require the involvement of counseling or social services.
Correct Answer is B
Explanation
Choice A rationale
Leaving the television on during the night may cause overstimulation in children with autism, disrupting their sleep patterns and leading to increased anxiety and agitation.
Choice B rationale
Minimizing physical contact respects the sensory sensitivities common in children with autism. Overwhelming sensory input from physical contact can cause distress and exacerbate behavioral issues.
Choice C rationale
Placing the child in a semi-private room can increase the risk of sensory overload and potential conflicts with roommates, as children with autism often struggle with shared spaces and the presence of unfamiliar people.
Choice D rationale
Forcing eye contact, especially when the child is agitated, can be distressing for children with autism. It may increase their agitation and make it harder for them to cope with their emotions and surroundings.
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