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?
Ensure that multiple nurses are present for the physical examination.
Reassure the child that no one will be told about the abuse.
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
A. Incorrect. While it’s important to have support during an examination, having multiple nurses present could be overwhelming for the child and may not be necessary. Instead, it's often best to have a single nurse and possibly a pediatric specialist or social worker present, ensuring the child feels safe and comfortable.
B. Incorrect. Reassuring the child that no one will be told is inappropriate as reporting suspected abuse is required by law.
C. Correct. It helps prepare the child for the next steps in the process and can reduce anxiety. Clear communication fosters trust and helps the child understand the importance of reporting for their safety and well-being.
D. Incorrect. Using leading statements can potentially affect the integrity of the investigation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. It is recommended to allow at least 1-2 minutes of rest between suction passes to minimize the risk of hypoxia and injury to the airway.
B. Incorrect. Suction is typically applied for 10-15 seconds while withdrawing the catheter to prevent hypoxia and trauma to the airway.
C. Incorrect. Coughing during suctioning can cause the client to aspirate secretions, which can be dangerous. The suctioning should be done quickly and efficiently without disturbing the client's airway.
D. Incorrect. The catheter should be attached to suction while being inserted and withdrawn to effectively clear secretions from the airway.
Correct Answer is B
Explanation
A. Incorrect. The natural loss of deciduous (baby) teeth typically begins around 6 years of age, not at 2 years old.
B. Correct. Toddlers often have a nontender, protruding abdomen due to their underdeveloped abdominal muscles.
C. Incorrect. The fontanels (soft spots on the baby's head) should be closed by 18-24 months of age. Palpable fontanels at 2 years old could indicate abnormal cranial development.
D. Incorrect. It is not typical for a 2-year-old's head circumference to exceed their chest circumference. Head circumference is usually greater in infants but gradually becomes similar to chest circumference by 1-2 years of age.
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