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NurseDive Free Nursing Practice Question
A nurse in an emergency department is assessing a school-age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse.
Which of the following actions should the nurse take?
A. Discuss the suspicion of physical abuse with the provider.
Discussing the suspicion of physical abuse with the provider is the appropriate action for the nurse to take. However, this should be done after the matter is reported to child protection services.
B. Confront the parents with the suspicion of physical abuse.
Confronting the parents with the suspicion of physical abuse is not an appropriate action for the nurse to take, as it can escalate the situation and endanger the child or the nurse.
C. Ask the hospital security to detain and question the parents.
Asking the hospital security to detain and question the parents is not an appropriate action for the nurse to take, as it violates the parents' rights and may interfere with the legal process.
D. Contact Child Protective Services.
Contacting Child Protective Services is appropriate action for the nurse to take at this point as it is the nurse's legal responsibility to do so.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
- A. Discussing the suspicion of physical abuse with the provider is the appropriate action for the nurse to take. However, this should be done after the matter is reported to child protection services.
- B. Confronting the parents with the suspicion of physical abuse is not an appropriate action for the nurse to take, as it can escalate the situation and endanger the child or the nurse.
- C. Asking the hospital security to detain and question the parents is not an appropriate action for the nurse to take, as it violates the parents' rights and may interfere with the legal process.
- D.Contacting Child Protective Services is appropriate action for the nurse to take at this point as it is the nurse's legal responsibility to do so.
Similar Questions
A nurse is caring for a client who is 1 hr postpartum.
Nurses' Notes 1200:
Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous JV infusion.
1215:
Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified.
Select the actions the nurse should take.
A. Firmly massage the uterine fundus.
Firmly massaging the uterine fundus helps to contract the uterus and reduce bleeding.
B. Provide emotional support.
Providing emotional support helps to calm the client and reduce anxiety, which can worsen bleeding.
C. Administer oxygen and Weigh the perineal pads.
Administering oxygen helps to improve tissue perfusion and oxygenation, which can be compromised by blood loss. Weighing the perineal pads helps to quantify the amount of blood loss and monitor for hemorrhage.
D. Insert indwelling urinary catheter and Administer methylergonovine.
Inserting an indwelling urinary catheter helps to empty the bladder and allow the uterus to descend and contract more effectively. Administering methylergonovine helps to stimulate uterine contractions and control bleeding.
E. Administer terbutaline.
Administering terbutaline is contraindicated in this situation, as it relaxes the uterine smooth muscle and increases bleeding.
Full Explanation
- A: Correct. Firmly massaging the uterine fundus helps to contract the uterus and reduce bleeding.
- B: Correct. Providing emotional support helps to calm the client and reduce anxiety, which can worsen bleeding.
- C: Correct. Administering oxygen helps to improve tissue perfusion and oxygenation, which can be compromised by blood loss. Weighing the perineal pads helps to quantify the amount of blood loss and monitor for hemorrhage.
- D: Correct. Inserting an indwelling urinary catheter helps to empty the bladder and allow the uterus to descend and contract more effectively. Administering methylergonovine helps to stimulate uterine contractions and control bleeding.
- E: Incorrect. Administering terbutaline is contraindicated in this situation, as it relaxes the uterine smooth muscle and increases bleeding.
A nurse is providing dietary teaching to a client who has a new prescription for phenelzine.
Which of the following food recommendations should the nurse make? (Select all that apply.)
A. Broccoli
Broccoli is a vegetable that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.
B. Yogurt
Yogurt is a dairy product that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.
C. Pepperoni pizza
Pepperoni pizza contains pepperoni, cheese, and tomato sauce, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.
D. Cream cheese
Cream cheese is a dairy product that contains tyramine, which can interact with phenelzine and cause a hypertensive crisis.
E. Bologna sandwich
Bologna sandwich contains bologna, bread, and mayonnaise, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.
Full Explanation
- A: Correct. Broccoli is a vegetable that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.
- B: Correct. Yogurt is a dairy product that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.
- C: Incorrect. Pepperoni pizza contains pepperoni, cheese, and tomato sauce, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.
- D: Cream cheese is a dairy product that contains little or no tyramine and is therefore, safe in a client taking phenelzine.
- E: Incorrect. Bologna sandwich contains bologna, bread, and mayonnaise, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.
A nurse is providing discharge teaching to a client who is to receive home oxygen therapy.
Which of the following instructions should the nurse include in the teaching?
A. Check the functioning of oxygen equipment once each week.
The nurse should check the functioning of oxygen equipment daily, not weekly, to ensure safety and proper delivery of oxygen.
B. Wear clothing made with cotton fabrics while oxygen is in use.
The nurse should instruct the client to wear clothing made with cotton fabrics while oxygen is in use, as synthetic fabrics can generate static electricity and cause sparks that could ignite the oxygen.
C. Apply petroleum-based lubricant to the nares as needed.
The nurse should instruct the client to avoid petroleum-based lubricants, such as Vaseline, as they are flammable and could cause burns if exposed to oxygen. The nurse should recommend water-soluble lubricants, such as K-Y jelly, instead.
D. Store full oxygen tanks on their side.
The nurse should instruct the client to store full oxygen tanks upright, not on their side, to prevent them from rolling and damaging the valve or regulator.
Full Explanation
- A. Incorrect. The nurse should check the functioning of oxygen equipment daily, not weekly, to ensure safety and proper delivery of oxygen.
- B. Correct. The nurse should instruct the client to wear clothing made with cotton fabrics while oxygen is in use, as synthetic fabrics can generate static electricity and cause sparks that could ignite the oxygen.
- C. Incorrect. The nurse should instruct the client to avoid petroleum-based lubricants, such as Vaseline, as they are flammable and could cause burns if exposed to oxygen. The nurse should recommend water-soluble lubricants, such as K-Y jelly, instead.
- D. Incorrect. The nurse should instruct the client to store full oxygen tanks upright, not on their side, to prevent them from rolling and damaging the valve or regulator.