A nurse is contributing to the care plan of an infant who has pneumonia.
Which of the following toys should the nurse select for the child's play activity?

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.

Choice A rationale

Decreased pressure in the cerebrospinal fluid (CSF) is not indicative of bacterial meningitis. In fact, increased CSF pressure is more commonly associated with meningitis due to inflammation and increased production of CSF. Monitoring CSF pressure helps diagnose and manage meningitis but decreased pressure would not support a bacterial meningitis diagnosis.

Choice B rationale

Decreased white blood cell (WBC) count in the CSF is not consistent with bacterial meningitis. Meningitis, especially bacterial, typically causes an increased WBC count in the CSF as the body responds to the infection. This increase in WBCs, particularly neutrophils, indicates the immune system's effort to combat the bacterial invasion. A decreased count would not align with this diagnosis.

Choice C rationale

Elevated glucose levels in the cerebrospinal fluid are not typical for bacterial meningitis. Bacterial infections usually consume glucose, leading to decreased glucose levels in the CSF. Elevated glucose levels could indicate other conditions or metabolic issues but would not support a bacterial meningitis diagnosis.

Choice D rationale

Elevated total protein in the cerebrospinal fluid supports the diagnosis of bacterial meningitis. In bacterial meningitis, the inflammation and increased permeability of the blood-brain barrier lead to elevated protein levels in the CSF. This finding, along with increased WBC count and decreased glucose levels, helps confirm the diagnosis of bacterial meningitis and guides appropriate treatment. .