A nurse is conducting a physical examination on a 4-year-old girl who was brought to the emergency department by her mother. The mother states that she found blood on her daughter's underwear and suspects that her boyfriend might have sexually abused her. Which of the following actions should the nurse take? (Select all that apply.)
Collect forensic evidence using a sexual assault kit.
Document any physical findings using body maps or diagrams.
Ask the mother to leave the room during the examination.
Use open-ended questions to elicit information from the child.
Perform a pelvic examination using a speculum.
Correct Answer : A,B,D
Choice A Reason: The nurse should collect forensic evidence using a sexual assault kit, which may include swabs, slides, envelopes, labels, and instructions for collecting specimens from various body sites. The nurse should follow the protocol for preserving and labeling the evidence.
Choice B Reason: The nurse should document any physical findings using body maps or diagrams, which can provide visual evidence of any injuries, bruises, abrasions, lacerations, or scars on the child's body. The nurse should also describe any findings using objective and precise language.
Choice C Reason: The nurse should not ask the mother to leave the room during the examination, unless she is suspected of being involved in the abuse or interfering with the assessment. The mother can provide emotional support and comfort to the child during this stressful situation.
Choice D Reason: The nurse should use open-ended questions to elicit information from the child, such as "What happened?" or "How do you feel?" The nurse should avoid leading or suggestive questions that may influence or distort the child's responses.
Choice E Reason: The nurse should not perform a pelvic examination using a speculum on a 4-year-old girl, unless it is medically indicated or ordered by a physician. A speculum examination can be traumatic and painful for a young child, and it may not yield useful information in cases of sexual abuse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This statement is not appropriate because it dismisses and invalidates the girl's feelings. It also implies that the girl is responsible for her abuse and that she can change her father's behavior.
Choice B Reason: This statement is not appropriate because it judges and labels the girl's feelings and her father's character. It also creates a dichotomy between good and bad, which may not reflect the complexity of the situation.
Choice C Reason: This statement is not appropriate because it minimizes and rationalizes the girl's abuse. It also shifts the blame from the father to his anger, which may not address the underlying causes of his violence.
Choice D Reason: This statement is appropriate because it acknowledges and validates the girl's feelings. It also explains that ambivalence is a common reaction among children who are abused by their parents, who may love them but also hurt them.
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A Reason: The nurse should report the suspicion to the child protective services, which is a legal and ethical obligation for nurses who work with children. The nurse should follow the policies and procedures of his or her institution and state laws regarding reporting.
Choice B Reason: The nurse should document the findings and observations in the medical record, which is a legal and ethical obligation for nurses who work with children. The nurse should use objective and precise language to describe any signs or symptoms of neglect.
Choice C Reason: The nurse should provide the boy with clean clothes, food, and a place to rest, which is a legal and ethical obligation for nurses who work with children. The nurse should address the immediate needs of the boy and ensure his comfort and safety.
Choice D Reason: The nurse should educate the parents about the importance of meeting their child's basic needs, which is a legal and ethical obligation for nurses who work with children. The nurse should offer support and guidance to the parents and provide information about available resources and services.
Choice E Reason: The nurse should refer the boy to a counselor or a social worker, which is a legal and ethical obligation for nurses who work with children. The nurse should recognize his or her scope of practice and collaborate with other health care providers to ensure holistic care for the boy and his family.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.