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 A
- A. Discussing the suspicion of physical abuse with the provider is the appropriate action for the nurse to take, as it allows for further assessment and documentation of the child's condition and possible referral to social services or law enforcement if needed.
- 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 not an appropriate action for the nurse to take at this point, as it requires confirmation of abuse by a provider or a court order before reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- A. Discussing the suspicion of physical abuse with the provider is the appropriate action for the nurse to take, as it allows for further assessment and documentation of the child's condition and possible referral to social services or law enforcement if needed.
- 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 not an appropriate action for the nurse to take at this point, as it requires confirmation of abuse by a provider or a court order before reporting.
Correct Answer is A
Explanation
Irritability.
The rationale for each choice is as follows:
- A. Irritability: Correct. Irritability is one of the signs of hypoglycemia, which occurs when blood glucose levels fall below 70 mg/dL (3.9 mmol/L). Other signs include shakiness, sweating, hunger, headache, confusion, and blurred vision.
- B. Increased urination: Incorrect. Increased urination is one of the signs of hyperglycemia, which occurs when blood glucose levels rise above 180 mg/dL (10 mmol/L). Other signs include thirst, dry mouth, fatigue, nausea, and fruity breath odor.
- C. Vomiting: Incorrect. Vomiting is not a specific sign of hypoglycemia or hyperglycemia, but it can occur as a complication of either condition if left untreated or poorly managed.
- D.Facial flushing: Incorrect. Facial flushing is not a sign of hypoglycemia or hyperglycemia, but it can occur as a side effect of some medications used to treat diabetes, such as niacin or rosiglitazone.
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