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 D
Explanation
A. Using a dime-sized amount of the medication is not the recommended instruction for tretinoin. A small, pea-sized amount is typically advised to avoid irritation and overuse.
B. Tretinoin should be applied at night, not in the morning, as it increases sensitivity to sunlight and can cause irritation when exposed to sunlight.
C. It is generally recommended to wait 20-30 minutes after washing the face before applying tretinoin, not just 5 minutes. This allows the skin to dry completely, reducing irritation.
D. Tretinoin can cause skin sensitivity, making the skin more prone to sunburn. Using a sunscreen with SPF 15 or higher is crucial to protect the skin from harmful UV rays while using tretinoin.
Correct Answer is A
Explanation
A. Tachycardia is a common finding in infants with heart failure. The body compensates for decreased cardiac output by increasing heart rate to maintain adequate perfusion to vital organs.
B. Blood pressure may not necessarily increase in heart failure. In fact, in severe cases, it can be low due to poor cardiac output.
C. Increased urinary output is not a typical manifestation of heart failure. In fact, heart failure often results in decreased renal perfusion, leading to decreased urine output.
D. Bounding peripheral pulses are usually seen in conditions like fever or hyperdynamic circulatory states, not in heart failure. In heart failure, peripheral pulses may be weak due to reduced cardiac output.
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