Summary
Summary ( 20 Questions)
A nurse is conducting a physical examination on a 4-year-old girl who was brought to the emergency department by her mother. The mother states that she found blood on her daughter's underwear and suspects that her boyfriend might have sexually abused her. Which of the following actions should the nurse take? (Select all that apply.)
Choice A Reason: The nurse should collect forensic evidence using a sexual assault kit, which may include swabs, slides, envelopes, labels, and instructions for collecting specimens from various body sites. The nurse should follow the protocol for preserving and labeling the evidence.
Choice B Reason: The nurse should document any physical findings using body maps or diagrams, which can provide visual evidence of any injuries, bruises, abrasions, lacerations, or scars on the child's body. The nurse should also describe any findings using objective and precise language.
Choice C Reason: The nurse should not ask the mother to leave the room during the examination, unless she is suspected of being involved in the abuse or interfering with the assessment. The mother can provide emotional support and comfort to the child during this stressful situation.
Choice D Reason: The nurse should use open-ended questions to elicit information from the child, such as "What happened?" or "How do you feel?" The nurse should avoid leading or suggestive questions that may influence or distort the child's responses.
Choice E Reason: The nurse should not perform a pelvic examination using a speculum on a 4-year-old girl, unless it is medically indicated or ordered by a physician. A speculum examination can be traumatic and painful for a young child, and it may not yield useful information in cases of sexual abuse.
Choice A Reason: The nurse should collect forensic evidence using a sexual assault kit, which may include swabs, slides, envelopes, labels, and instructions for collecting specimens from various body sites. The nurse should follow the protocol for preserving and labeling the evidence.
Choice B Reason: The nurse should document any physical findings using body maps or diagrams, which can provide visual evidence of any injuries, bruises, abrasions, lacerations, or scars on the child's body. The nurse should also describe any findings using objective and precise language.
Choice C Reason: The nurse should not ask the mother to leave the room during the examination, unless she is suspected of being involved in the abuse or interfering with the assessment. The mother can provide emotional support and comfort to the child during this stressful situation.
Choice D Reason: The nurse should use open-ended questions to elicit information from the child, such as "What happened?" or "How do you feel?" The nurse should avoid leading or suggestive questions that may influence or distort the child's responses.
Choice E Reason: The nurse should not perform a pelvic examination using a speculum on a 4-year-old girl, unless it is medically indicated or ordered by a physician. A speculum examination can be traumatic and painful for a young child, and it may not yield useful information in cases of sexual abuse.