A nurse is caring for a child who reports being abused by a family member. Which of the following statements should the nurse make?
"I promise I won't tell anyone about this."
"Your family is bad for doing this to you."
"It is not your fault that this happened."
"Let's discuss what you have told me with your family members."
The Correct Answer is C
Choice A reason: Promising secrecy is inappropriate because nurses are mandated reporters. They are legally and ethically obligated to report suspected child abuse. Making such a promise undermines trust when disclosure becomes necessary.
Choice B reason: Labeling the family as "bad" is judgmental and non-therapeutic. It risks alienating the child and does not provide supportive reassurance.
Choice C reason: Telling the child that it is not their fault is therapeutic and supportive. Children often internalize blame for abuse, so this statement helps reduce guilt and shame while validating their experience.
Choice D reason: Discussing the abuse directly with family members can place the child at further risk and is inappropriate. The nurse must follow mandated reporting procedures rather than confronting the family.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Setting an extra meeting time may reinforce manipulative behavior patterns common in borderline personality disorder.
Choice B reason: Ending at the scheduled time maintains boundaries and consistency, which are crucial in managing borderline personality disorder. It teaches respect for limits and prevents manipulation.
Choice C reason: Arranging for another nurse undermines continuity of care and does not address the boundary issue.
Choice D reason: Extending the time reinforces manipulative behavior and undermines therapeutic boundaries.
Correct Answer is D
Explanation
Choice A reason: Clients should maintain consistent sodium intake, not restrict it. Low sodium can increase lithium toxicity.
Choice B reason: Weight gain, not weight loss, is a common side effect of lithium.
Choice C reason: Fluid intake should not be restricted. Adequate hydration is essential to prevent lithium toxicity.
Choice D reason: Taking lithium with meals or milk reduces gastrointestinal irritation, making this the correct teaching point.
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