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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Sodium phosphate is commonly used as a bowel prep before a colonoscopy, and there is no immediate concern in this situation unless the client is showing signs of dehydration or electrolyte imbalances.
B. A positive Mantoux test induration indicates exposure to tuberculosis, which should be further evaluated, but it is not immediately urgent.
C. An increase in urinary frequency while taking bumetanide (a diuretic) is expected and should be monitored, but it is not a cause for alarm unless accompanied by other signs of dehydration or electrolyte imbalance.
D. Warfarin and breastfeeding require careful monitoring, as warfarin can pass into breast milk and affect the infant. The nurse should follow up on this situation to ensure the safety of both the mother and infant.

A. Use the balloon port to obtain the sterile specimen. B. Disconnect the catheter from the collection tubing. C. Unclamp the collection port below the bag. D. Obtain the specimen from the retention port.

Correct Answer is D

Explanation

A. Using the balloon port can contaminate the specimen and is not the proper method to obtain a sterile sample.
B. Disconnecting the catheter from the collection tubing can increase the risk of infection.
C. Unclamping the collection port could cause urine to back up into the catheter and introduce bacteria.
D. The retention port should be used to obtain a sterile specimen from the catheter, as it is designed for this purpose.

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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 D

Explanation

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Correct Answer is D

Explanation

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