A nurse in the emergency department is caring for a school-age child following an incidence of physical abuse. Which of the following statements should the nurse make?
"Explain what you were doing to get hit."
"Why do you think that you are being abused?"
"I am sure everything will work out just fine."
"Can you tell me how you are feeling?"
The Correct Answer is D
A. "Explain what you were doing to get hit." This statement implies blame or justification for the abuse and can cause the child to feel guilt or shame, which is inappropriate and non-therapeutic.
B. "Why do you think that you are being abused?" This question may sound accusatory or suggest that the child is responsible for the abuse. It can discourage open communication and retraumatize the child.
C. "I am sure everything will work out just fine." This is a false reassurance. It dismisses the child’s emotions and does not validate their experience, which can hinder trust-building.
D. "Can you tell me how you are feeling?" This open-ended, nonjudgmental question encourages the child to express emotions and builds therapeutic rapport. It provides emotional support in a safe, respectful manner.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Set the hot water heater to 52° C (125° F):This temperature is too high and increases the risk of scalding. The recommended setting for home water heaters is below 49° C (120° F) to prevent burns in infants and young children.
B. Place the playpen near a heat vent during cold weather:Placing the playpen near a heat vent can expose the infant to burns or overheating. It's important to maintain a safe distance from direct heat sources.
C. Position the crib away from the cords of blinds and drapes:This helps prevent strangulation hazards. Crib placement away from window cords and drapes is essential for newborn safety.
D. After feeding, place the newborn on his stomach:Placing a newborn on the stomach increases the risk of sudden infant death syndrome (SIDS). The correct position is on the back for sleep.
Correct Answer is D
Explanation
A. Measure the client’s rectal temperature daily:Rectal temperature measurement is contraindicated in immunosuppressed clients due to the risk of mucosal injury, which can introduce bacteria into the bloodstream and lead to sepsis.
B. Encourage ambulation in the facility’s hallways:While ambulation is beneficial for overall health, hallway ambulation exposes immunosuppressed clients to environmental pathogens and increases their infection risk. Exercise should be encouraged in a protected and sanitized space.
C. Monitor the client’s temperature every 8 hr:More frequent temperature monitoring is required in clients undergoing chemotherapy with immunosuppression, as even a slight elevation may signal an early infection. Monitoring every 8 hours may not be adequate.
D. Monitor the client’s WBC count daily:Daily monitoring of white blood cell count is essential to detect neutropenia early. A low WBC count increases the risk for infection, and frequent monitoring allows for timely interventions like protective isolation or treatment.
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