A nurse in a provider's office is assessing a school-age child who has a spiral fracture.
The parent of the child provides different accounts of the cause of the injury.
Which of the following actions should the nurse take first?

Report suspected abuse to Child Protective Services.

Determine the immediate safety needs of the child.

Request that the parent leave the room while interviewing the child.

Ask the child how the injury occurred.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Reporting suspected abuse to Child Protective Services is important when there are concerns of child abuse. However, in this scenario, the nurse's first priority should be to ensure the immediate safety and well-being of the child. Without assessing the child's safety, it would be premature to report abuse. Child Protective Services can be involved later if necessary.

Choice C rationale:

Requesting that the parent leave the room while interviewing the child can be a useful strategy when there are concerns about abuse or when the child needs to speak freely. However, this should not be the first action. Ensuring the child's immediate safety takes precedence.

Choice D rationale:

Asking the child how the injury occurred is important in gathering information, but it should not be the first action. Ensuring the child's safety is of primary importance, and this information can be gathered after immediate safety needs are addressed.

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Correct Answer is B

Explanation

Choice A rationale:

Offering prophylactic medication to prevent STIs is an important intervention in cases of sexual assault; however, it is not the next immediate step. The priority at this stage is to ensure the client's safety and emotional support.

Choice B rationale:

Providing a trained advocate to stay with the client is the most appropriate and immediate action. This helps ensure the client's emotional well-being and provides support during a traumatic experience. Advocates can also help the client navigate the healthcare system and legal processes.

Choice C rationale:

Conducting a pregnancy test is important, but it is not the next immediate step. Safety and emotional support should be the priority.

Choice D rationale:

Requesting a mental health consultation for the client is important, but it should not be the next immediate action. Safety and support should come first.

A. Offer the client advice about various treatment choices. B. Discourage the client from forming new relationships. C. Allow the client unlimited time for the grieving process. D. Change the subject when the client becomes upset.

Correct Answer is C

Explanation

Choice A rationale:

The nurse should not offer advice about various treatment choices to the client who has just received a terminal cancer diagnosis. At this point, the client should be provided with information about available treatment options by the healthcare provider. The nurse's role is to offer support, empathy, and help facilitate communication between the client and the provider. Offering advice about treatment choices is beyond the scope of the nurse's role in this situation.

Choice B rationale:

Discouraging the client from forming new relationships is not appropriate. The client's emotional and psychosocial needs are important, and it's essential to encourage meaningful connections and relationships, especially in a difficult time like receiving a terminal diagnosis. Isolation can have negative effects on the client's emotional well-being, so the nurse should support the client in maintaining relationships.

Choice D rationale:

Changing the subject when the client becomes upset is not an appropriate action. It's important for the nurse to provide emotional support and a listening ear to the client during this challenging time. Changing the subject may come across as dismissive or uncaring, and it does not address the client's emotional needs.

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A nurse in a provider's office is assessing a school-age child who has a spiral fracture.The parent of the child provides different accounts of the cause of the injury.Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the emergency department who states that she was beaten and sexually assaulted by her partner.After a rapid assessment, which of the following actions should the nurse plan to take next?

Correct Answer is B

Explanation

A nurse is caring for a client who has just received a terminal cancer diagnosis from his provider.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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A nurse in a provider's office is assessing a school-age child who has a spiral fracture.
The parent of the child provides different accounts of the cause of the injury.
Which of the following actions should the nurse take first?