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 C
Explanation
- A. Encourage the client to take a cool sponge bath each morning is not correct because it can increase joint stiffness and pain.
- B. Administer opioid analgesia is not correct because it is not the first-line treatment for rheumatoid arthritis and can cause dependence and tolerance.
- C. Increase the client's dietary iron intake is indicate in rheumatoid arthritis due to anemia of chronic inflammation.
- D. Restrict the client's intake of foods high in purines is incorrect in rheumatoid. It is an important measure in gouty arthritis.
Correct Answer is A
Explanation
Implement fall precautions for the client.
- A. Implement fall precautions for the client. This is correct because risperidone can cause orthostatic hypotension, which can increase the risk of falls and injuries. The nurse should advise the client to change positions slowly, avoid alcohol and dehydration, and use assistive devices as needed.
- B. Monitor the client's thyroid function. This is incorrect because risperidone does not affect thyroid function. The nurse should monitor the client's thyroid function if they are taking lithium, which can cause hypothyroidism.
- C. Place the client on a fluid restriction. This is incorrect because risperidone does not cause fluid retention or overload. The nurse should encourage adequate fluid intake and monitor the client's fluid balance.
- D. Discontinue the medication if hallucinations occur. This is incorrect because hallucinations are a symptom of schizophrenia, not a side effect of risperidone. The nurse should not discontinue the medication abruptly, as this can cause withdrawal symptoms and relapse of psychosis. The nurse should assess the client's response to the medication, report any adverse effects, and adjust the dosage as prescribed.
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