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,B,C,D,E
Explanation
A. The nurse should begin by donning sterile gloves to maintain a sterile field.
B. The suction machine should be turned on, and the pressure should be set before starting the suctioning.
C. The catheter should be inserted during the client’s inspiration to minimize discomfort and maximize
effectiveness.
D. Suction should be applied while rotating the catheter to prevent tissue damage and to clear secretions effectively.
E. After suctioning, the catheter should be rinsed to remove any remaining secretions.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
The client is at highest risk for developing mastitis as evidenced by the client'scracked nipple.
Rationale
The client has visible cracks on the left nipple, which is a key risk factor for mastitis. Cracked nipples can allow bacteria to enter the breast tissue during breastfeeding, leading to mastitis, especially if the nipples are not healing properly or the breastfeeding technique is suboptimal. The client also reports nipple discomfort throughout breastfeeding, which increases the likelihood of mastitis.
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