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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A client who is 1 day postoperative following a vertebroplasty may be stable enough for early discharge, freeing up a bed for incoming disaster victims.
B. A client with a sealed implant for radiation therapy may require monitoring and cannot be safely discharged early due to potential complications.
C. A client with COPD and a respiratory rate of 44/min requires immediate care and cannot be safely discharged.
D. A client receiving heparin for deep vein thrombosis may be stable but requires monitoring, making early discharge unsafe.
Correct Answer is A
Explanation
A. Instructing the client to avoid coughing during the procedure is important to prevent disrupting the needle placement during the thoracentesis.
B. The client should not be positioned in the prone position; instead, they are typically positioned upright and leaning forward to facilitate access to the pleural space.
C. Positioning the client on the affected side post-procedure may not be necessary unless ordered by the provider. Standard care includes positioning the client in an upright position after the procedure to promote lung expansion.
D. The client is generally not NPO for thoracentesis unless specified by the healthcare provider. The focus should be on ensuring comfort and informing the client about the procedure.
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