A nurse is caring for a child who reports being abused by a family member. Which of the following statements should the nurse make?
"I promise I won't tell anyone about this."
"Your family is bad for doing this to you."
"It is not your fault that this happened."
"Let's discuss what you have told me with your family members."
The Correct Answer is C
Choice A reason: Promising secrecy is inappropriate because nurses are mandated reporters. They are legally and ethically obligated to report suspected child abuse. Making such a promise undermines trust when disclosure becomes necessary.
Choice B reason: Labeling the family as "bad" is judgmental and non-therapeutic. It risks alienating the child and does not provide supportive reassurance.
Choice C reason: Telling the child that it is not their fault is therapeutic and supportive. Children often internalize blame for abuse, so this statement helps reduce guilt and shame while validating their experience.
Choice D reason: Discussing the abuse directly with family members can place the child at further risk and is inappropriate. The nurse must follow mandated reporting procedures rather than confronting the family.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Canceling the appointment delays necessary care and is not appropriate unless safety cannot be managed.
Choice B reason: Clients experiencing mania have short attention spans and difficulty processing complex information. Explaining the procedure in simple, clear terms is the most effective approach.
Choice C reason: A thorough explanation may overwhelm the client and increase agitation due to their inability to focus.
Choice D reason: Calling security preemptively is unnecessary unless there is a history of violence. It may escalate the situation and increase paranoia.
Correct Answer is D
Explanation
Choice A reason: Soup requires utensils and may be difficult for a client with poor concentration and hyperactivity to manage.
Choice B reason: A banana is easy to eat but does not provide adequate protein or sustained nutrition.
Choice C reason: Spaghetti requires utensils and is messy, making it impractical for a client in acute mania.
Choice D reason: A peanut butter sandwich is finger food, easy to eat, and provides protein and calories. It is the most appropriate choice for a client with mania who may struggle with focus and coordination.
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