A nurse is caring for a child who reports being physically abused by a family member. Which of the following statements should the nurse make?
"I promise I won't tell anyone about this."
"Let's discuss what you have told me with your family members."
"Your family is bad for doing this to you."
"It is not your fault that this happened."
The Correct Answer is D
A. "I promise I won't tell anyone about this.": This is inappropriate as nurses are mandated reporters and must inform authorities when abuse is suspected.
B. "Let's discuss what you have told me with your family members.": Involving the alleged abuser(s) directly can put the child at greater risk and is inappropriate.
C. "Your family is bad for doing this to you.": Judging or labeling the family is unprofessional and could make the child feel conflicted or guilty.
D. "It is not your fault that this happened.": This response reassures the child, alleviating feelings of guilt and fostering trust, while remaining supportive and professional.
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Correct Answer is C
Explanation
A. Reduce environmental stimuli: While minimizing stimuli is important for comfort, it is not the priority in treating a life-threatening bacterial infection.
B. Document intake and output: Monitoring fluid status is essential but secondary to administering life-saving treatment.
C. Administer antibiotics when available: Bacterial meningitis is a medical emergency. Administering antibiotics promptly can reduce mortality and prevent complications such as neurological damage.
D. Maintain seizure precautions: Seizure precautions are necessary but do not take precedence over starting antibiotics.
Correct Answer is ["A","D"]
Explanation
A. Clear the area of hard objects: This prevents injury to the child during the seizure.
B. Place a tongue depressor in the child's mouth: This is contraindicated as it can cause injury to the oral cavity or obstruct the airway.
C. Place the child in prone position: This position is unsafe during a seizure and could compromise the airway. The lateral position is recommended to reduce aspiration risk.
D. Loosen restrictive clothing: Loosening clothing promotes easier breathing and comfort during the seizure.