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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Correct. Informed consent means the client has the right to refuse treatment even after giving initial consent. The nurse should respect the client's autonomy and decision.

B. Incorrect. This statement does not respect the client's right to make decisions about her treatment.

C. Incorrect. While this statement might be true for some individuals, it does not address the client's current hesitation and does not respect her autonomy.

D. Incorrect. This statement does not address the client's expressed hesitation about the treatment.

A. Attends school regularly B. Caregiver reporting client acting differently than usual C. Witnessing their family's death D. Heart rate 99/min E. Smoking marijuana to clear their mind F. Client experiences nightmares G. Client experiences nightmares H. Startles easy during thunderstorm

Correct Answer is ["B","C","E","F"]

Explanation

A. Attends school regularly: While attending school regularly is important, it is not an immediate concern that requires follow-up compared to the other more pressing issues related to the traumatic event and the client's mental well-being.
B. Caregiver reporting client acting differently than usual: This finding requires immediate follow-up because it indicates a change in the client's behavior and could be indicative of emotional distress or mental health issues, especially considering the recent traumatic event they experienced.

C. Witnessing their family's death: Witnessing the death of family members in a traumatic event like a tornado is a significant and potentially traumatizing experience that requires immediate follow-up and support.
D. Heart rate 99/min: While a heart rate of 99/min is slightly elevated, it is not a critical finding that requires immediate follow-up in this context. The other findings are more relevant to the client's psychological well-being.
E. Smoking marijuana to clear their mind: The client's use of marijuana to cope with their thoughts and feelings should be addressed promptly, as it could indicate maladaptive coping mechanisms or potential substance abuse.
F. Client experiences nightmares: Experiencing nightmares could be a symptom of post-traumatic stress disorder (PTSD) or other mental health concerns related to the traumatic event.
G. BP 122/80 mm Hg: A blood pressure of 122/80 mm Hg is within a normal range and is not a cause for immediate concern.
H. Startles easy during thunderstorm: While startle responses can be related to anxiety, this specific finding is not as pressing as the client's reported coping mechanisms and traumatic experiences.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is ["B","C","E","F"]

Explanation

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