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?
Reassure the child that no one will be told about the abuse.
Use leading statements to obtain information from the child.
Explain to the child what will happen when the abuse is reported.
Ensure that multiple nurses are present for the physical examination.
The Correct Answer is C
A. The nurse must not promise confidentiality when abuse is suspected. Reporting is required by law, and the child should be informed of this.
B. Leading statements can influence the child’s response and should be avoided to ensure that information is accurately obtained.
C. Explaining the process to the child ensures that the child understands what will happen and can help alleviate anxiety about the situation.
D. While a supportive environment is important, the presence of multiple nurses during the physical examination could make the child feel uncomfortable. One nurse should be present to provide care and comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Delusions can contribute to aggressive behavior, but they are not as strong a predictor of future violence as a history of violent behavior.
B. While a history of incarceration may be a contributing factor, it does not predict future violence as strongly as previous violent behavior.
C. Previous violent behavior is the best predictor of future violence because it indicates a pattern of behavior that is likely to continue.
D. While male gender is a factor that may be associated with violence, it is not as predictive as a history of violent behavior.
Correct Answer is ["B","C","D","E"]
Explanation
A. Refuting delusions using logic can increase agitation and confusion. Instead, the nurse should offer reassurance and validation without arguing.
B. Giving the client one simple direction at a time helps minimize confusion and enhances the client’s
ability to follow instructions.
C. Establishing eye contact is important for communication and shows attentiveness, helping the client feel connected.
D. Allowing the client to choose among activities provides a sense of autonomy and can reduce agitation.
E. Reinforcing orientation helps maintain the client’s awareness of time, place, and person, which can reduce disorientation and anxiety.
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