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?
Reassure the child that no one will be told about the abuse.
Ensure that multiple nurses are present for the physical examination.
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
The correct answer is C. Explain to the child what will happen when the abuse is reported.
This is because the nurse should provide honest and accurate information to the child about the reporting process and the possible outcomes, such as legal actions, investigations, or removal from the home.
This can help the child feel more prepared and less anxious about what will happen next. The nurse should also reassure the child that the abuse is not their fault and that they did the right thing by telling someone.
Choice A is wrong because reassuring the child that no one will be told about the abuse is unethical and illegal.
The nurse has a mandatory duty to report any suspected or confirmed cases of child abuse to the appropriate authorities, such as child protective services or law enforcement. Keeping the abuse a secret can also endanger the child’s safety and well-being, as well as prevent them from receiving the necessary medical and psychological care.
Choice B is wrong because ensuring that multiple nurses are present for the physical examination can increase the child’s fear, embarrassment, or discomfort.
The nurse should minimize the number of people involved in the examination and only include those who are essential for providing care or collecting evidence. The nurse should also explain to the child what will be done during the examination and obtain their consent before proceeding.
Choice D is wrong because using leading statements to obtain information from the child can influence their responses and affect the validity of their testimony.
The nurse should use open-ended questions and avoid suggesting or implying any details about the abuse. The nurse should also document the child’s statements verbatim and avoid interpreting or paraphrasing them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. The nurse should sit in a chair next to the bed to place the client at ease. This position allows the nurse to maintain eye contact, show interest, and respect the client’s personal space. Sitting on the bed next to the client (choice A) is wrong because it invades the client’s privacy and comfort zone. Standing at the side of the bed (choice C) or at the foot of the bed (choice D) is wrong because it creates a power imbalance and may intimidate the client.
The nurse should also consider the client’s condition and preferences when choosing a position for the interview. For example, a client who is on bedrest may have difficulty hearing or seeing the nurse if they are too far away or at an awkward angle.
Therefore, the nurse should adjust their position accordingly and ask the client if they are comfortable with it.
Correct Answer is C
Explanation
Choice A reason:
"This test will be repeated when your baby is 2 months old. “This is a false statement. Newborn genetic screening is usually performed shortly after birth. The test is not typically repeated when the baby is 2 months old, as it is meant to detect conditions early on, allowing for prompt intervention and management if necessary.
Choice B reason:
"Your baby will be given 2 ounces of water to drink prior to the test."This is a false statement. The baby does not need to drink water before the newborn genetic screening test. The test is usually performed by collecting a small blood sample from the baby's heel, and there is no need for the baby to drink water beforehand.
Choice C reason:
"This test should be performed after your baby is 24 hours old. “This is the appropriate statement. The nurse should include the statement that newborn genetic screening should be performed after the baby is 24 hours old. Newborn genetic screening, also known as newborn screening or heel prick test, is a standard test performed on newborns to detect certain genetic, metabolic, and congenital disorders early on. The test is typically done by pricking the baby's heel to collect a small sample of blood, which is then analysed in a laboratory.
Choice D reason:
"A nurse will draw blood from your baby's inner elbow. “This is a false statement. The correct location for collecting the blood sample for newborn genetic screening is the baby's heel. The nurse will prick the baby's heel to obtain a few drops of blood, which will then be collected on a special filter paper for laboratory analysis.
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