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. Continuously monitor the child’s respiratory status. This is because epiglottitis is a life-threatening condition that can cause severe airway obstruction and respiratory distress in children. The nurse should monitor the child for signs of worsening breathing, such as stridor, cyanosis, restlessness, or drooling. The nurse should also be prepared to assist with intubation or tracheostomy if needed.
Choice A is wrong because assessing the child for frequent swallowing may increase the risk of vomiting and aspiration. Swallowing may also be difficult and painful for the child due to the inflammation of the epiglottis.
Choice C is wrong because suctioning the child’s oropharynx may cause more swelling and irritation of the epiglottis, or trigger a spasm that can close off the airway. The nurse should avoid any stimulation of the throat or mouth that may worsen the condition.
Choice D is wrong because administering pancreatic enzymes with meals is not relevant to epiglottitis. Pancreatic enzymes are used to treat cystic fibrosis, a genetic disorder that affects the lungs and digestive system. Epiglottitis is caused by a bacterial infection or an injury to the throat.
Correct Answer is A
Explanation
The correct answer is choice A. Deep tendon reflexes 2+. This indicates that the client is receiving the therapeutic effect of magnesium sulfate, which is to prevent seizures by reducing neuromuscular excitability.
Magnesium sulfate is a mineral that is given intravenously to women with preeclampsia, a condition of high blood pressure and protein in the urine during pregnancy, to reduce the risk of seizures or eclampsia. It can also prolong pregnancy for up to two days, allowing drugs that speed up the baby’s lung development to be administered.
Choice B is wrong because 1+ proteinuria via urine dipstick is not a therapeutic effect of magnesium sulfate, but a sign of preeclampsia.
Proteinuria indicates that the kidneys are not working properly and are leaking protein into the urine. Magnesium sulfate does not improve the outcomes for the baby and can cause side effects such as respiratory depression for the mother.
Choice C is wrong because pulse rate 100/min is not a therapeutic effect of magnesium sulfate, but a possible side effect.
Magnesium sulfate can cause vasodilation, which lowers blood pressure and increases heart rate. A normal pulse rate for an adult is between 60 and 100 beats per minute. A pulse rate higher than 100 beats per minute may indicate tachycardia, which can be caused by various factors such as anxiety, dehydration, fever, infection, or medication.
Choice D is wrong because urine output 20 mL/hr is not a therapeutic effect of magnesium sulfate, but a sign of kidney failure. A normal urine output for an adult is between 800 and 2000 mL per day, or about 30 to 80 mL per hour. A urine output lower than 30 mL per hour may indicate oliguria, which can be caused by various factors such as dehydration, blood loss, shock, or kidney damage. Magnesium sulfate can cause renal toxicity if given in high doses or for prolonged periods.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today