A nurse in the emergency department is assessing a preschool-age child who has bruises on both arms and a spiral fracture of the left ulna. The child's parent tells the nurse that the child tripped over some toys and fell down. Which of the following actions should the nurse take?
Take pictures of the child's injuries once the parent leaves the room.
Have a facility security officer interview the parent.
Complete an incident report concerning the child's injuries.
Report the child's injuries to Child Protective Services.
The Correct Answer is D
Choice A reason: Taking pictures of the child's injuries once the parent leaves the room is not a correct action, as it violates the child's privacy and dignity. The nurse should not take pictures of the child without the parent's consent and only if it is required by the facility's policy or the law.
Choice B reason: Having a facility security officer interview the parent is not a correct action, as it is not within the scope of the security officer's role and may escalate the situation. The nurse should not involve the security officer unless there is a threat of violence or harm to the child, the parent, or the staff.
Choice C reason: Completing an incident report concerning the child's injuries is not a correct action, as it is not relevant to the child's situation. The nurse should complete an incident report only if there is an adverse event or error that occurred within the facility that affected the child's care or safety.
Choice D reason: Reporting the child's injuries to Child Protective Services is the correct action, as it is the nurse's legal and ethical duty to protect the child from potential abuse or neglect. The nurse should suspect child abuse based on the child's injuries, which are inconsistent with the parent's explanation and indicative of non-accidental trauma. The nurse should follow the facility's protocol and the state's law for reporting suspected child abuse.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The most recent blood glucose reading is not the most important information for the nurse to report at shift change. IV corticosteroids can cause hyperglycemia, which requires monitoring and treatment, but it is not as critical as the client's level of consciousness.
Choice B reason: The laboratory tests scheduled for next shift are not the most important information for the nurse to report at shift change. The nurse should inform the oncoming nurse about the tests, but they are not as urgent as the client's neurological status.
Choice C reason: The reddened area on the coccyx is not the most important information for the nurse to report at shift change. The nurse should document and report any signs of skin breakdown, but they are not as life-threatening as the client's increased intracranial pressure.
Choice D reason: The Glasgow Coma Scale score is the most important information for the nurse to report at shift change. The Glasgow Coma Scale is a tool that measures the client's level of consciousness based on eye opening, verbal response, and motor response. A decrease in the score indicates a deterioration in the client's neurological condition, which requires immediate intervention.
Correct Answer is B
Explanation
Choice A reason: This is not the correct choice because this assignment is not appropriate for a licensed practical nurse. A client who requires discharge instructions for type 1 diabetes mellitus needs education on self-care, medication administration, blood glucose monitoring, diet, and exercise. These are complex tasks that require the knowledge and skills of a registered nurse.
Choice B reason: This is the correct choice because this assignment is appropriate for a licensed practical nurse. A client who is 1 day postoperative and has a continuous bladder irrigation needs routine care, such as vital signs, wound assessment, fluid intake and output, and catheter care. These are basic tasks that can be performed by a licensed practical nurse under the supervision of a registered nurse.
Choice C reason: This is not the correct choice because this assignment is not appropriate for a licensed practical nurse. A client who requires a blood transfusion to be administered needs careful monitoring, such as checking for compatibility, verifying informed consent, observing for adverse reactions, and documenting the transfusion. These are advanced tasks that require the judgment and authority of a registered nurse.
Choice D reason: This is not the correct choice because this assignment is not appropriate for a licensed practical nurse. A client who is receiving IV chemotherapy needs specialized care, such as preparing and administering the medication, managing side effects, providing emotional support, and following safety precautions. These are specialized tasks that require the training and certification of a registered nurse.
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