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 B

Explanation

A. Incorrect. Avoiding the issue by scheduling the nurses to have fewer shifts together might not address the underlying conflict and could lead to resentment.

B. Correct. Encouraging collaboration empowers the nurses to work together and find common ground in making assignments.

C. Incorrect. While promising more equitable assignments is important, addressing the conflict directly and encouraging collaboration is a more proactive approach.

D. Incorrect. Asking each nurse to take turns making the assignments might not resolve the perceived favoritism and could create further tension.

A. Determine if the client's health care surrogate is aware of the risks and benefits of the procedure. B. Ensure that the client's family supports the provider's decision for surgery. C. Determine if the procedure is medically necessary for the client. D. Send the unsigned informed consent form to the facility's risk manager.

Correct Answer is A

Explanation

A. Correct. In cases where the client is unable to provide informed consent due to incapacitation, the health care surrogate or legally authorized representative should be involved in the decision-making process.
B. Incorrect. While family support is important, the decision for surgery should primarily be based on medical necessity and the best interests of the client.
C. Incorrect. Determining medical necessity is the responsibility of the medical team, not the nurse.
D. Incorrect. Sending the unsigned informed consent form to the risk manager is not a standard nursing responsibility and does not address the issue of informed consent.

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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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