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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Restraints should never be attached to the side rails, as this can increase the risk of injury.
B. The client's condition should be documented every 15 minutes to ensure their safety and comfort while in restraints.
C. A PRN prescription for restraints is not appropriate; restraints should be used only as a last resort and with a physician's order.
D. The restraint should be removed at least every 2 hours to assess for skin integrity and allow for range- of-motion exercises.
Correct Answer is C
Explanation
A. A pulse rate of 100/min is within the expected range and is not an indication for concern with magnesium sulfate administration.
B. Proteinuria of 1+ indicates mild protein in the urine, which is a sign of preeclampsia, not necessarily a therapeutic effect of magnesium sulfate.
C. Monitoring deep tendon reflexes for signs of magnesium sulfate toxicity (e.g., loss of reflexes) is essential.
D. Urine output of 20 mL/hr is below the expected output and may indicate toxicity or kidney issues, so it should be carefully monitored.
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