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 A
Explanation
A. Encouraging the family to involve siblings in the care of the terminally ill child is important for fostering family support, allowing siblings to understand the situation, and promoting emotional bonding.
B. Avoiding discussions about death is not recommended. It is important to communicate with the child about death in an age-appropriate manner to help them understand and cope with the situation.
C. While monitoring vital signs is important, it is not the most therapeutic intervention in the final stages of terminal illness. Comfort care, including pain management and emotional support, takes priority.
D. Passive range of motion is not essential for a child in the final stages of terminal illness unless necessary for specific comfort or mobility needs. Care should focus on comfort measures rather than routine interventions.
Correct Answer is D
Explanation
A. Growth and changes in height and weight accelerate during adolescence, particularly in the early years, as part of the growth spurt.
B. While it is important to involve parents, adolescent clients should be encouraged to participate in decision-making about their health, as they are developing autonomy. Health decisions should include both the adolescent and the parents when possible.
C. Adolescents are often highly interested in discussing health promotion, particularly topics that are relevant to their peer group, such as body image, sexual health, and mental health.
D. The timing of puberty can significantly impact an adolescent’s self-esteem. Early or late onset of puberty may lead to feelings of self-consciousness or social challenges. Understanding this developmental change is essential in supporting the adolescent’s emotional and psychological well-being.
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