A nurse is talking privately with an adolescent who has disclosed that their facial fractures are the result of their punishment for coming home 1 hr after their curfew. Which of the following responses should the nurse make?
"I won't tell anyone else about this unless you say it's okay."
"Your parent was wrong to hit you for coming home late."
"I'm guessing your other parent did not do anything to stop this from happening."
"It is not your fault that this happened to you."
The Correct Answer is D
A. While it is important to maintain confidentiality, the nurse must follow mandatory reporting laws for suspected abuse, which may require informing appropriate authorities.
B. While it may be important to acknowledge the harm done, directly labeling the parent's behavior as "wrong" could potentially escalate the situation and may not be helpful in building rapport with the adolescent.
C. Making assumptions about the behavior of another parent can be seen as judgmental and may not be helpful in addressing the adolescent’s concerns or in facilitating a safe environment for disclosure.
D. This response provides reassurance to the adolescent that they are not responsible for the abuse and helps to create a nonjudgmental, supportive environment, allowing the adolescent to feel safe and heard.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The rooting reflex should be present at 1 month of age, not absent. This reflex is triggered when the infant’s cheek is stroked, prompting the baby to turn their head toward the stimulus and open their mouth.
B. A respiratory rate of 64/min is within the expected range for a 1-month-old infant, whose normal respiratory rate is typically between 30–60 breaths per minute.
C. Head lag is normal at 1 month of age when the infant's head is lifted while they are in a sitting position. However, by 4 months of age, the infant should have more head control and reduced head lag.
D. Yellow sclera indicates jaundice, which is common in newborns but should be assessed if present at 1 month to ensure it resolves. By this time, any jaundice should be resolving or gone.
Correct Answer is A
Explanation
A. The posterior iliac crest is the typical site for bone marrow aspiration in children. Placing the child in the prone position allows for proper access to the site while ensuring the child remains safe and stable during the procedure.
B. Positioning the child side-lying would expose the vertebrae but is not an optimal position for accessing the iliac crest for bone marrow aspiration.
C. The frog-like position (supine with legs flexed outward) is not an appropriate position for a bone marrow aspiration, as it does not provide the best access to the iliac crest or posterior iliac crest.
D. Sitting with the buttocks at the edge of the table would not adequately expose the posterior iliac crest, making it unsuitable for bone marrow aspiration.
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