A nurse in an emergency department is assessing a school-age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse.
Which of the following actions should the nurse take?
Discuss the suspicion of physical abuse with the provider.
Confront the parents with the suspicion of physical abuse.
Ask the hospital security to detain and question the parents.
Contact Child Protective Services.
The Correct Answer is D
- A. Discussing the suspicion of physical abuse with the provider is the appropriate action for the nurse to take. However, this should be done after the matter is reported to child protection services.
- B. Confronting the parents with the suspicion of physical abuse is not an appropriate action for the nurse to take, as it can escalate the situation and endanger the child or the nurse.
- C. Asking the hospital security to detain and question the parents is not an appropriate action for the nurse to take, as it violates the parents' rights and may interfere with the legal process.
- D.Contacting Child Protective Services is appropriate action for the nurse to take at this point as it is the nurse's legal responsibility to do so.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Assign the client to a private room with negative air pressure.
Rationale:
- A. Incorrect. Restricting fresh flowers from the client's room is not necessary for infection control purposes. However, some clients with pulmonary tuberculosis may have hypersensitivity reactions to certain plants or flowers, so the nurse should assess the client's allergies before allowing them in the room.
- B. Incorrect. Maintaining a distance of 1.8 m (6 feet) from the client is not sufficient to prevent transmission of tuberculosis. Visitors should also wear a HEPA respirator and limit their contact time with the client.
- C. Incorrect. A surgical mask is not adequate to protect the nurse from inhaling airborne droplet nuclei that contain Mycobacterium tuberculosis. The nurse should wear a high-efficiency particulate air (HEPA) respirator when providing client care.
- D. Correct. Assigning the client to a private room with negative air pressure is the most effective way to prevent the spread of tuberculosis to other clients and staff members. The room should have at least six air exchanges per hour and an exhaust system that vents directly to the outside.
Correct Answer is C
Explanation
Choice C rationale:
The client's speech, "Tie a bow. Row the boat. Now I know. Whoa! I see you, yo," is an example of word salad. Word salad is a disorganized mixture of words and phrases that lack coherent meaning and logical connection. It is often observed in severe cases of schizophrenia or other mental health disorders and indicates a significant impairment in thought process and communication. In word salad, words and phrases are randomly juxtaposed, making it difficult to understand the intended message.
Choice A rationale:
Neologisms are newly coined words or phrases that have meaning only to the individual using them. Neologisms are often created by individuals with mental disorders and might not make sense to others. In the given speech, the words and phrases, although disorganized, are not newly coined or invented terms, so neologisms do not apply here. **
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