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 C
Explanation
A. This is a stimulant laxative that works by increasing the movement of the intestines, helping the stool to come out. However, given the client's third-degree perineal laceration, a rectal suppository might cause discomfort and potentially disrupt the healing process.
B. Incorrect. Loperamide is an antidiarrheal medication and is not appropriate for constipation relief.
C. This is an osmotic laxative that works by drawing water into the intestines, which helps to soften the stool and stimulate bowel movements. It is taken orally and would not interfere with the healing of the perineal laceration.
D. Incorrect. Famotidine is an H2 blocker used to reduce stomach acid and is not indicated for constipation relief.
Correct Answer is C
Explanation
A. Incorrect. Family history of malignant hypertension is not a contraindication for alteplase.
B. Incorrect. COPD itself is not a contraindication for alteplase. While it can complicate overall management, it does not increase the immediate risk of bleeding associated with thrombolytics.
C. Correct. Recent surgery, especially orthopedic surgery like hip arthroplasty, is a contraindication for thrombolytic therapy due to the increased risk of bleeding and hematoma formation at the surgical site.
D. Incorrect. Acute renal failure from six months ago is not a contraindication for alteplase.
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