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 A

Explanation

A. Assessing for the characteristic erythema migrans (bullseye rash) and other manifestations of Lyme disease is important for early detection and treatment.
B. Lyme disease is not contagious and does not require isolation or restrictions on sharing personal belongings.
C. Antitoxin is not used for Lyme disease; antibiotics are the primary treatment.
D. While Lyme disease should be reported, it is not a mandatory report to the state health department unless there is an outbreak or specific reporting requirements.

A. Bulging fontanels B. Hypertonicity C. Bradycardia D. Acrocyanosis

Correct Answer is B

Explanation

A. Bulging fontanels are a sign of increased intracranial pressure, not withdrawal.
B. Hypertonicity (muscle rigidity) is a common sign of neonatal withdrawal from opioids like methadone.
C. Bradycardia is not typically associated with opioid withdrawal in newborns.
D. Acrocyanosis is a normal finding in newborns and is not related to withdrawal.

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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

A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take?

Correct Answer is A

Explanation

A nurse is caring for a newborn whose mother was taking methadone during her pregnancy. Which of the following findings indicates the newborn is experiencing withdrawal?

Correct Answer is B

Explanation

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