A nurse is caring for a school-age child who has a fractured arm and other injuries that cause the nurse to suspect abuse. Which of the following actions is appropriate for the nurse to take when assessing the child's situation?
Direct the parents to the waiting room before interviewing the child.
Interview the child with the provider and social worker present.
Ask clarifying questions as the child explains how the injuries occurred.
Ask the parents directly if the child's fracture is due to physical abuse.
The Correct Answer is C
Choice A reason: Separating the child from the parents is appropriate, but interviewing the child alone may not be ideal. Having trained professionals present ensures proper documentation and support.
Choice B reason: Interviewing the child with the provider and social worker ensures a trauma-informed, multidisciplinary approach. It protects the child and ensures accurate assessment.
Choice C reason: Asking clarifying questions is acceptable, but the nurse must avoid leading or suggestive questioning. The presence of trained professionals helps maintain objectivity.
Choice D reason: Directly asking the parents may lead to denial or defensiveness. It is not the recommended approach in suspected abuse cases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Administering medication may help reduce agitation, but it is not the first-line intervention in an acute crisis. Medication takes time to act and does not immediately address the safety threat. It is more appropriate after initial de-escalation efforts have failed or in conjunction with other strategies.
Choice B reason: Setting limits is the least restrictive and most immediate intervention to ensure safety. It helps establish boundaries, reduce escalation, and maintain control of the situation. This aligns with psychiatric nursing principles that prioritize safety while preserving autonomy and dignity.
Choice C reason: Restraints are considered a last resort due to their physical and psychological risks. They should only be used when all other interventions have failed and there is imminent danger to the client or others.
Choice D reason: Seclusion is also a restrictive intervention and should only be used when less restrictive measures are ineffective. It may be necessary in some cases, but it is not the priority unless the client cannot be managed safely through verbal de-escalation and limit-setting.
Correct Answer is D
Explanation
Choice A reason: Living in a hallway shelter may reflect unstable housing, which is a risk factor for relapse, but it is not as direct a barrier as residing with someone actively using substances.
Choice B reason: Restlessness and poor sleep hygiene are symptoms that may complicate recovery but are not primary barriers unless they interfere with treatment adherence.
Choice C reason: Identifying triggers is a protective factor, not a barrier. It shows insight and readiness for relapse prevention planning.
Choice D reason: Staying with someone who is actively using substances creates a high-risk environment for relapse and undermines recovery efforts. This is a direct and significant barrier.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.