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. Measuring gastric residual volumes every 4 hours is important to assess gastric emptying and to determine if the client can tolerate the feedings. If residuals are high, it may indicate delayed gastric emptying and the need to adjust the feeding rate.
B. Incorrect. While flushing the NG tube before and after medications is important to maintain patency, it is typically done with sterile water, not sodium chloride, unless otherwise specified by a protocol. Therefore, this statement may not be fully accurate.
C. Incorrect. The head of the bed should be elevated to a 30-45° angle to help prevent aspiration during enteral feedings.
D. Incorrect. The rate of the feeding should be advanced gradually to prevent overloading the client's gastrointestinal tract. This does not involve advancing the rate every 2 hours.
Correct Answer is A
Explanation
A. Correct. Banana slices are a soft and easily manageable food that encourages a toddler's independence in eating. They can be easily held by the toddler and self-fed.
B. Incorrect. Hot dogs are a choking hazard due to their shape and texture, which can increase the risk of choking in young children.
C. Incorrect. Grapes are also a choking hazard for young children, as they can easily block the airway if not cut into small pieces.
D. Incorrect. Popcorn is a choking hazard due to its size, shape, and hardness. It should be avoided in young children.
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