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. Using an electronic messaging system to remind clients when to take medications is an example of tertiaryprevention, as it aims to prevent the development of complications.
B. Helping clients understand health screenings covered by their insurance plans can be considered primary or secondary prevention, depending on the context.
C. Incorrect. Providing clients with information about the benefits of exercise is an example of health promotion, which is also a component of primary prevention.
D. Educating clients about contraindications to specific immunizations falls under tertiary prevention, which aims to minimize the impact of an illness or condition that is already present.

A. Scrambled eggs and toast with milk B. Bacon and cheese quiche with milk C. Ham sandwich with milk D. Shrimp salad and tomato soup with milk

Correct Answer is A

Explanation

A. Correct. Scrambled eggs and toast are generally kosher-friendly options. However, milk may not be suitable if the client keeps kosher dietary laws, as it cannot be mixed with meat in the same meal.

B. Incorrect. Bacon and cheese quiche contain pork (bacon), which is not kosher.

C. Incorrect. Ham is pork and is not considered kosher.

D. Incorrect. Shrimp and milk are not kosher foods.

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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

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