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A nurse in an emergency department is caring for a child who reports being sexually abused by a family member. Which of the following actions should the nurse take?
- A. Use leading statements to obtain information from the child
- B. Ensure that multiple nurses are present for the physical examination
- C. Explain to the child what will happen when the abuse is reported
- D. Reassure the child that no one will be told about the abuse
Correct Answer: C
Rationale: Correct Answer: C - Explain to the child what will happen when the abuse is reported.
Rationale: It is crucial for the nurse to inform the child about the reporting process to ensure transparency and build trust. This empowers the child and helps them understand the next steps. It also promotes their involvement in decision-making regarding their well-being. By explaining the process, the nurse can offer emotional support and reassurance to the child. This approach respects the child's autonomy and dignity.
Incorrect Choices:
A: Using leading statements can influence the child's responses and compromise the accuracy of information obtained.
B: Having multiple nurses present may intimidate the child and breach confidentiality.
D: Reassuring the child that no one will be told about the abuse may perpetuate feelings of isolation and hinder the necessary intervention.
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A nurse is caring for a 2-year-old toddler. Which of the following food choices should the nurse recommend to promote independence in eating?
- A. Banana slices
- B. Grapes
- C. Hot dog
- D. Popcorn
Correct Answer: A
Rationale: The correct answer is A: Banana slices. Toddlers at the age of 2 are developing their fine motor skills and independence. Banana slices are easy for toddlers to pick up and eat independently, promoting their self-feeding skills. Grapes pose a choking hazard due to their size and shape. Hot dogs are also a choking hazard as they can easily get stuck in a toddler's throat. Popcorn is a common choking hazard for young children due to its hard texture. Therefore, recommending banana slices will not only promote independence in eating but also ensure safety for the toddler.
Which of the following statements should the nurse make?
- A. We can initiate medical care until you get legal assistance in preparing your advance directives.
- B. Advance directives can be signed without legal representation.
- C. Advance directives can be a verbal agreement between you and your provider until legal review can be obtained.
- D. A social worker will assist you to find affordable legal representation.
Correct Answer: B
Rationale: The correct answer is B: Advance directives can be signed without legal representation. This is correct because advance directives are legal documents that individuals can complete on their own without the need for a lawyer. They allow individuals to specify their healthcare wishes in advance. Choice A is incorrect as medical care can be initiated regardless of advance directives. Choice C is incorrect as advance directives must be in writing to be legally valid. Choice D is incorrect as social workers typically provide support but do not usually offer legal representation.
Which of the following actions should the nurse take first?
- A. Determine the client's Glasgow Coma Scale score
- B. Insert an indwelling urinary catheter for the client.
- C. Administer mannitol IV bolus to the client
- D. Prepare the client for an MRI of the brain.
Correct Answer: A
Rationale: The correct answer is A: Determine the client's Glasgow Coma Scale (GCS) score. This is the priority action as it helps assess the client's level of consciousness and neurological status quickly. It guides further interventions and treatment decisions. Inserting an indwelling urinary catheter (B) or administering mannitol IV bolus (C) may be needed but assessing neurological status comes first. Preparing for an MRI (D) is important but not the initial step.
A charge, nurse is teaching new staff members about factors that increase a client's risk to become violent: Which of the following risk factors should the nurse include as the best predictor of future violence?
- A. A history of being in prison
- B. Male gender
- C. Experiencing delusions
- D. Previous violent behavior
Correct Answer: D
Rationale: The correct answer is D: Previous violent behavior. This is the best predictor of future violence because past behavior is a strong indicator of future actions. Individuals who have a history of violent behavior are more likely to engage in violent acts again. Choice A (A history of being in prison) is not as strong of a predictor as it does not specifically address violent behavior. Choice B (Male gender) is a generalization and not always indicative of violent behavior. Choice C (Experiencing delusions) may increase the risk of violence but does not directly predict future violent behavior as strongly as previous violent actions do.
A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel (AP) telling the client,If you don't eat I'll put restraints on your wrists and feed you." The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?"
- A. Battery
- B. Assault
- C. Negligence
- D. Malpractice
Correct Answer: B
Rationale: The correct answer is B: Assault. Assault refers to the threat of harmful or offensive contact without the actual contact occurring. In this scenario, the AP's statement of putting restraints on the client constitutes a threat of physical harm, which falls under the definition of assault. The nurse should intervene to prevent any potential harm to the client. The other choices are incorrect because: A: Battery involves actual harmful or offensive contact, which has not occurred in this situation. C: Negligence refers to a failure to provide reasonable care, not a threat of harm. D: Malpractice involves professional negligence or misconduct, which is not demonstrated in this scenario.