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 C
Explanation
Choice A reason: The prodromal stage is the period between the exposure to the infectious agent and the onset of specific symptoms. During this stage, the person may experience mild and nonspecific signs of infection, such as fatigue or lowgrade fever. The client in the question has already developed specific symptoms of infection, such as sneezing, productive cough, and fever, which indicate that they have passed the prodromal stage.
Choice B reason: The period of convalescence is the stage of recovery after the infection. During this stage, the person's symptoms gradually subside, and their immune system eliminates the infectious agent from the body. The client in the question is still experiencing symptoms of infection, which suggest that they have not reached the period of convalescence yet.
Choice C reason: The acute illness stage is the peak of the infection, when the person exhibits the most severe and specific symptoms of the disease. During this stage, the person's immune system fights against the infectious agent, and the outcome of the infection is determined. The client in the question is likely in the acute illness stage, as they have been experiencing symptoms of infection for 4 days, and their condition has worsened over time.
Choice D reason: The incubation stage is the time between the entry of the infectious agent into the body and the appearance of the first symptoms of infection. During this stage, the person does not feel ill, but the infectious agent is multiplying in the body. The client in the question has already developed symptoms of infection, which indicate that they have left the incubation stage.
Correct Answer is D
Explanation
Choice A reason: There are not 4 rights of delegation, but 5 rights of delegation. The 5 rights of delegation are the right task, the right circumstance, the right person, the right direction or communication, and the right supervision or evaluation. The nurse should know and apply these rights when delegating tasks to other members of the health care team.
Choice B reason: The nurse manager is not the only one responsible for delegating nursing tasks during each shift, but the registered nurse (RN) is also responsible for delegating nursing tasks within their scope of practice. The RN should delegate tasks based on the client's needs, the staff's competencies, and the organizational policies. The nurse manager should support and oversee the delegation process, but not assume the sole responsibility for it.
Choice C reason: It is not the duty of the delegate to perform a task without asking questions when it is delegated, but to ask questions or clarify any doubts or concerns before accepting or performing the task. The delegate should communicate effectively with the delegator and ensure that they understand the task, the expected outcome, the time frame, and the resources available. The delegate should also report any problems or issues that arise during or after the task completion.
Choice D reason: I am responsible for ensuring that a delegated task is completed is a correct statement that indicates understanding of delegation. The delegator is accountable for the decision to delegate and the outcome of the task. The delegator should monitor and evaluate the performance and the results of the task, and provide feedback and recognition to the delegate. The delegator should also intervene or take corrective actions if needed.
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