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 {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
The client is at highest risk for developing mastitis as evidenced by the client'scracked nipple.
Rationale
The client has visible cracks on the left nipple, which is a key risk factor for mastitis. Cracked nipples can allow bacteria to enter the breast tissue during breastfeeding, leading to mastitis, especially if the nipples are not healing properly or the breastfeeding technique is suboptimal. The client also reports nipple discomfort throughout breastfeeding, which increases the likelihood of mastitis.
Correct Answer is B
Explanation
A. Epistaxis (nosebleeds) is not a common manifestation of hypovolemia. It is more typically associated with conditions like hypertension or nasal trauma.
B. Dizziness is a common symptom of hypovolemia due to reduced blood volume and decreased perfusion to the brain.
C. Shortness of breath is more likely to occur with conditions such as pulmonary edema or respiratory disorders, not hypovolemia.
D. Headache can occur in hypovolemia due to reduced blood flow, but dizziness is more directly related to the body's inability to compensate for low blood volume.
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