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

Choice A rationale:

Looping the tubing so that it is lower than the collection bag creates a dependent loop where urine can pool, increasing the risk of UTI. This practice should be avoided as it can lead to bacterial contamination and subsequent infections.

Choice B rationale:

Keeping the urinary bag at bladder level when ambulating helps maintain a continuous flow of urine into the collection bag without creating dependent loops. This practice minimizes the risk of bacterial contamination and reduces the chances of acquiring a UTI.

Choice C rationale:

Obtaining urinary samples by disconnecting the tubing connections is not recommended. This procedure can introduce bacteria into the urinary system, increasing the risk of UTI. Sterile techniques, such as using a catheter port for sampling, should be followed to minimize the risk of infection.

Choice D rationale:

Securing the catheter to the client's thigh is essential to prevent tension and pulling on the catheter, which can cause trauma to the urethra. However, securing the catheter alone does not minimize the risk of UTI. Proper hygiene, closed drainage system, and maintaining a continuous flow of urine into the collection bag are key factors in preventing UTIs in clients with indwelling urinary catheters.

A. Evaluate the client's ability to help with repositioning. B. Reposition the client without the use of assistive devices. C. Discuss the client's preferences for determining a repositioning schedule. D. Raise the side rails on both sides of the client's bed during repositioning.

Correct Answer is A

Explanation

A. Correct. Evaluating the client's ability to assist with repositioning is important to ensure safe and appropriate positioning that considers the client's capabilities and comfort.
B. Incorrect. The use of assistive devices or assistance from the nurse or other personnel may be necessary to ensure safe repositioning, especially in clients with mobility limitations.
C. Incorrect. While discussing the client's preferences is important, it may not directly relate to the immediate need for repositioning after a stroke.
D. Incorrect. Raising the side rails on both sides of the bed is important for client's safety, but it doesn't address the client's need for repositioning after a stroke.

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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

A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter.Which of the following actions should the nurse take to help minimize the client's risk for acquiring a UTI?

Correct Answer is B

Explanation

A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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