A nurse is caring for a client who has cancer and is terminally ill.

The client reports feeling depressed.

Which of the following statements should the nurse make?

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.

The correct answer is choice B. Use an ibuterol inhaler.

Choice A rationale:

Completing oral hygiene is important for overall health, but it is not specifically related to the preparation for postural drainage in cystic fibrosis patients. Postural drainage is a technique used to clear mucus from the lungs, and oral hygiene does not directly affect this process.

Choice B rationale:

Using a bronchodilator, such as an ibuterol inhaler, is recommended before postural drainage because it helps to open the airways, making the drainage process more effective. Bronchodilators are often used to relax the muscles around the airways, which can become constricted in conditions like cystic fibrosis.

Choice C rationale:

Taking pancrelipase is related to aiding digestion in cystic fibrosis patients who have pancreatic insufficiency. While it is an important part of the overall management of cystic fibrosis, it is not directly related to the preparation for postural drainage.

Choice D rationale:

Eating a meal before postural drainage is not recommended because a full stomach can make the process uncomfortable and less effective. It is generally advised to perform postural drainage on an empty stomach to ensure that the mucus can be cleared from the lungs more easily.