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 D

Explanation

A. Incorrect. Encouraging the client to lie down in a quiet room is not specifically related to addressing auditory hallucinations.
B. Incorrect. Referring to hallucinations as if they are real can reinforce the client's delusions or hallucinations.
C. Incorrect. Avoiding eye contact can be perceived as dismissive or uninterested.
D. Correct. Asking the client directly about their hallucinations helps assess their content and severity, which is essential for developing an effective plan of care.

A. Decreased temperature. B. Polyuria. C. Bradycardia. D. Increased respiratory rate.

Correct Answer is D

Explanation

Choice A rationale:

Decreased temperature is not a typical sign of naloxone reversing the effects of an opioid overdose. Opioid overdose commonly leads to respiratory depression and hypoxia, but it does not significantly affect body temperature. Naloxone works by binding to the same receptors in the brain that opioids bind to, thereby reversing the effects of the overdose. The primary signs of successful reversal include improved respiratory rate and increased alertness, not changes in body temperature.

Choice B rationale:

Polyuria (excessive urination) is not a specific indicator of naloxone effectiveness. Opioid overdose and naloxone administration primarily affect the central nervous system and respiratory function, not urinary output. Naloxone's effects are more evident in the client's level of consciousness, respiratory rate, and overall responsiveness.

Choice C rationale:

Bradycardia (slow heart rate) is not an expected indicator of naloxone effectiveness. Opioid overdose typically causes respiratory depression, leading to a decreased respiratory rate and oxygen saturation. Naloxone works by reversing this respiratory depression and improving ventilation. Consequently, increased respiratory rate, not heart rate, is a more relevant indicator of naloxone's effectiveness in reversing opioid overdose.

Choice D rationale:

This is the correct answer. Increased respiratory rate is a key indicator that naloxone is reversing the effects of an opioid overdose. Opioid overdose depresses the respiratory system, leading to slow and shallow breathing. Naloxone, as an opioid receptor antagonist, rapidly reverses this effect, leading to a noticeable increase in the client's respiratory rate. Monitoring for improved breathing and increased oxygen saturation is crucial to assessing the effectiveness of naloxone in treating opioid overdose.

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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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Correct Answer is D

Explanation

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