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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because the nurse should establish eye contact and rapport with the client, not the interpreter, and show respect for the client’s culture and autonomy. The nurse should also use simple and clear language, avoid jargon and slang, and speak in short sentences.
Choice A is wrong because using gestures to convey meaning can be confusing or offensive to some cultures. The nurse should avoid relying on nonverbal communication and ask the interpreter for clarification if needed.
Choice B is wrong because pausing in the middle of sentences can disrupt the flow of communication and make it harder for the interpreter to translate accurately. The nurse should pause at the end of each complete thought or sentence to allow the interpreter to relay the information.
Choice C is wrong because speaking slowly when talking to the interpreter can imply that the interpreter is incompetent or unintelligent. The nurse should speak at a normal pace and tone, and allow enough time for the interpreter to translate.
Correct Answer is C
Explanation
Administer sublingual nitroglycerin.
Nitroglycerin is a vasodilator that can relieve chest pain caused by myocardial ischemia. The nurse should administer it as soon as possible to improve blood flow to the heart and reduce the risk of myocardial infarction. The nurse should also monitor the client’s blood pressure and heart rate after giving nitroglycerin, as it can cause hypotension and reflex tachycardia.
Choice A is wrong because checking a STAT cardiac troponin is not the first priority.
Cardiac troponin is a biomarker that indicates myocardial injury, but it may not rise until several hours after the onset of chest pain.
Therefore, it is not useful for immediate diagnosis or treatment of acute coronary syndrome. Choice B is wrong because requesting a prescription for a beta-blocker is not the first priority.
Beta-blockers are medications that can lower blood pressure and heart rate, and reduce the oxygen demand of the heart.
They can prevent or reduce the recurrence of chest pain and complications of acute coronary syndrome, but they are not indicated for immediate relief of chest pain.
Choice D is wrong because administering oxygen is not the first priority.
Oxygen therapy can increase the oxygen supply to the heart and reduce ischemia, but it is not necessary for all clients with chest pain.
Oxygen therapy should be based on the client’s oxygen saturation level and clinical condition.
If the client’s oxygen saturation is normal or high, oxygen therapy may not be beneficial and may even be harmful.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today