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.

Ensure that multiple nurses are present for the physical examination.

Explain to the child what will happen when the abuse is reported.

Use leading statements to obtain information from the child.

Answer and Explanation

The Correct Answer is C

This is because the nurse should provide honest and accurate information to the child about the reporting process and the possible outcomes, such as legal actions, investigations, or removal from the home.
This can help the child feel more prepared and less anxious about what will happen next. The nurse should also reassure the child that the abuse is not their fault and that they did the right thing by telling someone.

Choice A is wrong because reassuring the child that no one will be told about the abuse is unethical and illegal.
The nurse has a mandatory duty to report any suspected or confirmed cases of child abuse to the appropriate authorities, such as child protective services or law enforcement. Keeping the abuse a secret can also endanger the child’s safety and well-being, as well as prevent them from receiving the necessary medical and psychological care.

Choice B is wrong because ensuring that multiple nurses are present for the physical examination can increase the child’s fear, embarrassment, or discomfort.
The nurse should minimize the number of people involved in the examination and only include those who are essential for providing care or collecting evidence. The nurse should also explain to the child what will be done during the examination and obtain their consent before proceeding.

Choice D is wrong because using leading statements to obtain information from the child can influence their responses and affect the validity of their testimony.
The nurse should use open-ended questions and avoid suggesting or implying any details about the abuse. The nurse should also document the child’s statements verbatim and avoid interpreting or paraphrasing them.

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Correct Answer is B

Explanation

The correct answer is choice b. Using an electronic messaging system to remind clients when to take medications.

Choice A rationale:

Educating clients about contraindications to specific immunizations is an example of primary prevention, which aims to prevent disease before it occurs.

Choice B rationale:

Using an electronic messaging system to remind clients when to take medications is an example of tertiary prevention. It helps manage an existing condition (HIV) by ensuring adherence to treatment, thereby preventing complications and improving quality of life.

Choice C rationale:

Providing clients with information about the benefits of exercise is generally considered primary prevention, as it aims to promote overall health and prevent disease.

Choice D rationale:

Helping clients understand health screenings covered by their insurance plans is an example of secondary prevention, which focuses on early detection and treatment of disease.

A. Document the client’s condition every 15 min. B. Request a PRN restraint prescription for clients who are aggressive. C. Attach the restraint to the bed’s side rails. D. Remove the client’s restraint every 4 hr.

Correct Answer is A

Explanation

The correct answer is choice A.

Choice A rationale:

Documenting the client’s condition every 15 minutes is a crucial part of using restraints. Regular documentation helps ensure the safety and well-being of the client, as it allows for continuous monitoring and timely intervention if necessary.

Choice B rationale:

Requesting a PRN (as needed) restraint prescription for clients who are aggressive is not a recommended practice. Restraints should only be used as a last resort and must be based on a thorough assessment of the client’s condition, not solely on their behavior.

Choice C rationale:

Attaching the restraint to the bed’s side rails is not recommended. This can increase the risk of injury to the client. Restraints should be attached to a part of the bed frame that moves with the client, such as the head or footboard.

Choice D rationale:

While it’s important to regularly check and adjust restraints for comfort and safety, there’s no specific guideline that restraints should be removed every 4 hours. The frequency of removal and repositioning will depend on the individual client’s condition and needs.

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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 A

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