A nurse in a pediatric clinic is caring for a school-age child who has a perforated eardrum. The nurse suspects abuse. Which of the following actions should the nurse take?

Inform the parents that the findings must be reported to authorities.

Complete an incident report for risk management.

Interview the child about the suspected abuse with a parent present.

Avoid asking the child what caused the injury.

Answer and Explanation

The Correct Answer is A

Choice A reason: If a nurse suspects child abuse, they are legally required to report it to the appropriate authorities. Informing the parents that the findings must be reported is necessary to comply with mandatory reporting laws. This step ensures that the child receives the necessary protection and that the situation is investigated further by child protective services or law enforcement.

Choice B reason: Completing an incident report for risk management is an internal process used by healthcare facilities to document incidents that occur within the facility. While it is important to document the findings, this action alone does not fulfill the nurse's legal obligation to report suspected abuse to the authorities.

Choice C reason: Interviewing the child about the suspected abuse with a parent present may not be appropriate, especially if there is a possibility that the parent is the abuser. The presence of the parent could influence the child's responses and prevent them from speaking freely about the abuse. It is crucial to conduct the interview in a safe and supportive environment, often with a child protection professional or a social worker.

Choice D reason: Avoiding asking the child what caused the injury is not recommended in cases of suspected abuse. It is important for the nurse to gather as much information as possible about the cause of the injury. However, the nurse should approach the questioning in a sensitive and non-leading manner to avoid further traumatizing the child.

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Correct Answer is D

Explanation

Choice A reason: Going to their room alone when feeling overwhelmed may indicate that the client is trying to manage their emotions, but it does not directly address the effectiveness of the safety contract. The goal of the contract is to ensure that the client seeks help and communicates their feelings of self-harm to a healthcare provider.

Choice B reason: Displacing feelings of self-harm until talking to the provider is not a clear indication of the contract's effectiveness. The client may still be at risk of self-harm if they do not have immediate access to the provider. The safety contract aims to encourage the client to seek help and communicate their feelings promptly.

Choice C reason: Suppressing feelings when angry is not a healthy coping mechanism and does not indicate the effectiveness of the safety contract. The contract should promote open communication and seeking help rather than suppressing emotions, which can lead to further distress and potential self-harm.

Choice D reason: Notifying the nurse when they want to harm themselves is a clear indication that the safety contract has been effective. The client is following the agreed-upon plan to seek help and communicate their feelings of self-harm, which is the primary goal of the safety contract. This behavior demonstrates that the client is taking steps to ensure their safety and seeking support from healthcare providers.

A. "I will be informing the provider about this conversation." B. "You should continue this conversation in a private place." C. "It is an invasion of privacy to discuss that information." D. "If you are going to talk about a client in public, do not use their name."

Correct Answer is C

Explanation

Choice A reason: Informing the provider about the conversation might be necessary if there are concerns about confidentiality breaches, but it does not address the immediate issue of discussing private patient information in a public place. The charge nurse's first responsibility is to stop the inappropriate discussion and remind the staff nurse about the importance of maintaining patient privacy.

Choice B reason: While continuing the conversation in a private place is better than discussing it in a public hallway, the staff nurse should not be discussing private patient information unless it is necessary for the patient's care. The charge nurse should emphasize the importance of confidentiality and ensure that such conversations occur only when necessary and in appropriate settings.

Choice C reason: This response directly addresses the issue of discussing private patient information and reinforces the importance of maintaining confidentiality. By stating that it is an invasion of privacy to discuss the information, the charge nurse makes it clear that such conversations are inappropriate and should not occur.

Choice D reason: Telling the staff nurse not to use the client's name in public discussions misses the broader point about confidentiality. Even without using a name, discussing specific details about a patient's condition or admission can still breach their privacy. The charge nurse should emphasize the importance of not discussing patient information in public settings at all.

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A nurse in a pediatric clinic is caring for a school-age child who has a perforated eardrum. The nurse suspects abuse. Which of the following actions should the nurse take?

Nursing Test Bank

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Correct Answer is C

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