A nurse is collecting data from a child and notes the presence of bruises on her arms and legs. Which of the following actions should the nurse take first?
Obtain a detailed history.
Report the suspected abuse to the authorities.
Request a social services referral.
Tell the child what will happen to her when the abuse is reported.
The Correct Answer is A
Choice A reason: Obtaining a detailed history is the first action that the nurse should take. History can help the nurse determine the cause, frequency, and severity of the bruises, as well as the child's relationship with the abuser and the risk of further harm. History can also help the nurse assess the child's physical and emotional state, and provide evidence for reporting the abuse later.
Choice B reason: Reporting the suspected abuse to the authorities is not the first action that the nurse should take. The nurse should report the abuse only after obtaining a history and confirming the suspicion. Reporting the abuse prematurely can jeopardize the child's safety and the nurse's credibility. The nurse should also follow the legal and ethical guidelines for reporting abuse in their jurisdiction.
Choice C reason: Requesting a social services referral is not the first action that the nurse should take. The nurse should request a social services referral only after reporting the abuse and ensuring the child's protection. A social services referral can help the child access resources and support, such as counseling, legal aid, foster care, etc. The nurse should also collaborate with the social worker and other members of the interdisciplinary team to provide holistic care for the child.
Choice D reason: Telling the child what will happen to her when the abuse is reported is not the first action that the nurse should take. The nurse should tell the child what will happen to her only after obtaining a history and reporting the abuse. The nurse should also use age-appropriate language and reassure the child that the abuse is not her fault and that she is not alone. The nurse should avoid making promises that they cannot keep, such as saying that the abuser will never hurt her again.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A sentinel event is a serious adverse event that results in death, permanent harm, or severe temporary harm to a patient. Administering incompatible blood products to a client is a sentinel event because it can cause fatal hemolytic reactions.
Choice B reason: Administering client medications 30 minutes late is not a sentinel event, unless it leads to a serious adverse outcome for the patient. Medication errors are common and preventable, and they should be reported and analyzed to improve patient safety.
Choice C reason: Documenting vital signs at the wrong time in the client’s electronic health record is not a sentinel event, unless it leads to a serious adverse outcome for the patient. Documentation errors are also common and preventable, and they should be corrected and avoided to ensure accurate and timely information.
Choice D reason: Administering a prescribed sedative to a client for insomnia is not a sentinel event, unless it leads to a serious adverse outcome for the patient. Sedatives are commonly used to treat insomnia, and they should be prescribed and administered with caution and monitoring⁵.
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect because administering an antiemetic to a client who has post chemotherapy nausea is not medically futile. It is a supportive measure that can help the client to manage the side effects of chemotherapy and improve their comfort and quality of life.
Choice B reason: This statement is incorrect because administering a narcotic analgesic to a client who has end stage cancer is not medically futile. It is a palliative measure that can help the client to relieve their pain and suffering and improve their comfort and quality of life.
Choice C reason: This statement is incorrect because administering oral care for a client who has post chemotherapy mucositis is not medically futile. It is a preventive measure that can help the client to avoid infections and complications and improve their oral health and hygiene.
Choice D reason: This statement is correct because administering chemotherapy to a client who has metastatic cancer is medically futile. It is a curative measure that has no reasonable chance of achieving its intended goal of eradicating the cancer or prolonging the client's survival. It may also cause harm or distress to the client by exposing them to unnecessary risks and side effects.
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