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 A
Explanation
A. A client who is ambulatory and receiving oxygen should be evacuated first because they are mobile and their oxygen needs may put them at increased risk in a fire.
B. A client who is bedridden and wears a hearing aid may need more assistance but does not have immediate life-threatening needs during evacuation.
C. A client with a fracture in balance suspension traction requires careful handling but can be evacuated after those at greater risk.
D. A client who uses a wheelchair and is confused may need help but is not at the highest risk for immediate harm during a fire evacuation.
Correct Answer is D
Explanation
A. Encouraging the client to spend time in the dayroom may increase stimulation and worsen manic symptoms. A quiet, calm environment is typically more beneficial.
B. Withdrawing privileges is punitive and may escalate agitation or irritability in a client with mania.
C. Seclusion should only be used if the client is a danger to themselves or others. It is not a first-line intervention for anxiety or manic symptoms.
D. Encouraging the client to take frequent rest periods helps manage manic symptoms by preventing fatigue and promoting some level of structure and control over their activities.
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