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A nurse in a pediatric clinic is caring for a school-age child who has a perforated eardrum. The nurse suspects abuse. Which of the following actions should the nurse take?
- A. Inform the parents that the findings must be reported to authorities.
- B. Complete an incident report for risk management.
- C. Interview the child about the suspected abuse with a parent present.
- D. Avoid asking the child what caused the injury.
Correct Answer: A
Rationale: If a nurse suspects child abuse, they are legally required to report it to the appropriate authorities. Informing the parents that the findings must be reported is necessary to comply with mandatory reporting laws. This step ensures that the child receives the necessary protection and that the situation is investigated further by child protective services or law enforcement.
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A nurse is collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?
- A. Low tolerance for frustration.
- B. Involved in community activities.
- C. Submissive personality.
- D. Absence of impulsive behaviors.
Correct Answer: A
Rationale: Low tolerance for frustration is a significant risk factor for becoming a perpetrator of child abuse. Individuals who have difficulty managing their frustration may be more likely to react impulsively and aggressively when faced with challenging situations. This inability to cope with frustration can lead to abusive behaviors, especially if the individual has not developed healthy coping mechanisms.
A nurse is contributing to the plan of care for a client who has schizophrenia. The client often directs brief
- A. hostile verbal outbursts toward the staff. Which of the following interventions should the nurse recommend?
- B. Encourage the client to participate in a board game.
- C. Touch the client on the shoulder to console them.
- D. Bring a security guard whenever approaching the client.
- E. Use a calm, clear tone when speaking to the client.
Correct Answer: D
Rationale: Using a calm, clear tone when speaking to the client is an effective intervention for managing hostile verbal outbursts. Calm communication helps de-escalate the situation and prevents further agitation. It shows the client that the nurse is in control and can provide a stable, reassuring presence, which is essential for building trust and maintaining a therapeutic environment.
A nurse is collecting data from a group of clients in an acute care mental health facility. For which of the following findings should the nurse be most concerned regarding individual client safety?
- A. A client who has borderline personality disorder and acts impulsively
- B. A client who has avoidant personality disorder and becomes anxious in social situations
- C. A client who has dependent personality disorder and clings to nursing staff
- D. A client who has histrionic personality disorder and seeks constant attention
Correct Answer: A
Rationale: Clients with borderline personality disorder (BPD) who act impulsively can be a significant safety concern. Impulsive behaviors in BPD can include self-harm, suicidal ideation, substance abuse, and other risky actions. These behaviors can pose immediate and severe threats to the client's safety and require close monitoring, intervention, and support.
A nurse is assisting in the care of an adolescent who states
- A. I hate living at home. It's impossible to please my parents. Which of the following responses should the nurse make?
- B. Your parents care for you and want what's best for you.
- C. Let's talk about your relationship with your parents.
- D. Why do you think your parents are hard to please?
- E. Things will get better as time goes on.
Correct Answer: B
Rationale: This response opens up a conversation about the adolescent's feelings and experiences regarding their relationship with their parents. It shows empathy and a willingness to understand the adolescent's perspective, which can help build trust and rapport. By exploring the relationship, the nurse can gather more information and provide appropriate support and guidance.
A nurse is caring for a client who has delirium. Which of the following findings should the nurse expect?
- A. Gradual onset
- B. Impaired judgment
- C. Difficulty swallowing
- D. Slowed, flat speech
Correct Answer: B
Rationale: Impaired judgment is a common finding in delirium. Clients with delirium often have fluctuating levels of consciousness, attention deficits, and disorganized thinking, all of which can contribute to poor judgment. This cognitive impairment can lead to unsafe behaviors and difficulty in making decisions.