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 B
Explanation
Choice A reason: The hospital supervisor is not the first person to notify, as they are not directly responsible for the unit or the staff. The hospital supervisor is usually a senior nurse who oversees the operations of the entire hospital or a specific shift. They may be involved in the later stages of the reporting process, but not as the initial contact.
Choice B reason: The charge nurse is the first person to notify, as they are the immediate supervisor of the unit and the staff. The charge nurse is usually an experienced nurse who coordinates the care and activities of the unit, assigns tasks, and provides guidance and support to the staff. They have the authority and responsibility to address the situation and take appropriate actions.
Choice C reason: The chief nursing officer is not the first person to notify, as they are not directly involved in the unit or the staff. The chief nursing officer is usually the highestranking nurse in the organization, who oversees the nursing practice, quality, and education across the entire system. They may be informed of the situation by the unit director or the hospital supervisor, but not as the initial contact.
Choice D reason: The unit director is not the first person to notify, as they are not directly available on the unit or the staff. The unit director is usually a nurse manager who oversees the administrative and financial aspects of the unit, such as budgeting, staffing, and evaluation. They may be notified of the situation by the charge nurse or the hospital supervisor, but not as the initial contact.
Correct Answer is D
Explanation
Choice A reason: This statement is false and should not be included in the teaching. Placing the client on 12hour observation is not enough to ensure the client's safety, as the client may still attempt suicide when the nurse is not watching. The client should be placed on continuous observation, preferably one-to-one, until the risk of suicide is reduced.
Choice B reason: This statement is false and should not be included in the teaching. Encouraging visitors to bring items to the client is not advisable, as some items may pose a potential danger to the client, such as sharp objects, medications, or alcohol. The nurse should inspect and limit the items that the client and the visitors have access to, and remove any items that could be used for self-harm.
Choice C reason: This statement is false and should not be included in the teaching. Encouraging visitors for the client at any time is not appropriate, as some visitors may have a negative impact on the client, such as those who are abusive, judgmental, or unsupportive. The nurse should screen and monitor the visitors, and allow only those who are helpful and respectful to the client.
Choice D reason: This statement is true and should be included in the teaching. Removing harmful objects from the client's room is a priority action that the nurse should take to prevent the client from harming themselves. The nurse should search the client's room and belongings, and remove any objects that could be used for suicide, such as knives, scissors, razors, belts, cords, or plastic bags.
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