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?

Ensure that multiple nurses are present for the physical examination.

Reassure the child that no one will be told about the abuse.

Explain to the child what will happen when the abuse is reported.

Use leading statements to obtain information from the child.

Answer and Explanation

The Correct Answer is C

A.   Incorrect. While it’s important to have support during an examination, having multiple nurses present could be overwhelming for the child and may not be necessary. Instead, it's often best to have a single nurse and possibly a pediatric specialist or social worker present, ensuring the child feels safe and comfortable.
B.   Incorrect. Reassuring the child that no one will be told is inappropriate as reporting suspected abuse is required by law.
C.   Correct. It helps prepare the child for the next steps in the process and can reduce anxiety. Clear communication fosters trust and helps the child understand the importance of reporting for their safety and well-being.
D.   Incorrect. Using leading statements can potentially affect the integrity of the investigation.

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Correct Answer is B

Explanation

A. Incorrect. A pale appearance and fluid deficit of 30 mL over 24 hours might require intervention but is not as critical as sunken fontanels and dry mucous membranes.

B. Correct. Sunken fontanels and dry mucous membranes are signs of dehydration, a potential complication of gastroenteritis. These findings should be reported to the provider for further evaluation and intervention.

C. Incorrect. A slightly elevated temperature and an increased pulse rate are common responses to infection and fever in infants.

D. Incorrect. Decreased appetite and irritability can be expected in infants with gastroenteritis and are not as concerning as signs of dehydration.

A. Document the client's level of understanding about potential adverse effects. B. Teach the client how to insert the diaphragm. C. Determine the client's knowledge about diaphragm use. D. Supervise return demonstration of diaphragm use.

Correct Answer is C

Explanation

A. Incorrect. Documenting the client's understanding of adverse effects is important, but ensuring the client's knowledge about diaphragm use is the first step.

B. Incorrect. Teaching the client how to insert the diaphragm can be an important step, but first, it's essential to assess the client's existing knowledge.

C. Correct. Before proceeding with teaching or other actions, it's important to determine the client's baseline understanding of diaphragm use.

D. Incorrect. Supervising the return demonstration is important but should come after the client's knowledge level is assessed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is C

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