A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse.
The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?

This is because the nurse should provide honest and accurate information to the child about the reporting process and the possible outcomes, such as legal actions, investigations, or removal from the home.
This can help the child feel more prepared and less anxious about what will happen next. The nurse should also reassure the child that the abuse is not their fault and that they did the right thing by telling someone.

Choice A is wrong because reassuring the child that no one will be told about the abuse is unethical and illegal.
The nurse has a mandatory duty to report any suspected or confirmed cases of child abuse to the appropriate authorities, such as child protective services or law enforcement. Keeping the abuse a secret can also endanger the child’s safety and well-being, as well as prevent them from receiving the necessary medical and psychological care.

Choice B is wrong because ensuring that multiple nurses are present for the physical examination can increase the child’s fear, embarrassment, or discomfort.
The nurse should minimize the number of people involved in the examination and only include those who are essential for providing care or collecting evidence. The nurse should also explain to the child what will be done during the examination and obtain their consent before proceeding.

Choice D is wrong because using leading statements to obtain information from the child can influence their responses and affect the validity of their testimony.
The nurse should use open-ended questions and avoid suggesting or implying any details about the abuse. The nurse should also document the child’s statements verbatim and avoid interpreting or paraphrasing them.

Valsartan is a medication that lowers blood pressure by blocking the action of angiotensin II, a hormone that causes blood vessels to constrict. By dilating the blood vessels, valsartan reduces the pressure in the arteries and improves blood flow to the organs. However, if the dose of valsartan is too high, it can cause excessive lowering of blood pressure, which can lead to symptoms such as dizziness, fainting, blurred vision, or nausea. This is especially likely when the client changes position from lying or sitting to standing, which is called orthostatic hypotension. Therefore, the nurse should monitor the client’s blood pressure and pulse in different positions and report any significant changes to the provider. The nurse should also instruct the client to rise slowly from a lying or sitting position and to avoid driving or operating machinery until the effects of the medication wear off.

Choice A is wrong because monitoring the client’s urine output is not a priority action for a client who received an overdose of valsartan.

Valsartan does not have a direct effect on urine output, although it may affect kidney function in some cases. The nurse should monitor the client’s serum creatinine and blood urea nitrogen levels to assess kidney function, but this is not as urgent as evaluating the client for orthostatic hypotension.

Choice B is wrong because checking the client for nasal congestion is not a priority action for a client who received an overdose of valsartan.

Nasal congestion is not a common or serious side effect of valsartan. It is more likely to occur with other types of blood pressure medications, such as angiotensin-converting enzyme (ACE) inhibitors or beta blockers.

Choice D is wrong because obtaining the client’s laboratory results is not a priority action for a client who received an overdose of valsartan.

Laboratory results may provide useful information about the client’s electrolyte levels, kidney function, liver function, or blood counts, but they are not as important as assessing the client’s vital signs and symptoms of hypotension. The nurse should obtain the laboratory results after stabilizing the client’s blood pressure and ensuring adequate perfusion to the organs.