A nurse reports an incident of suspected child abuse. One of the child's parents becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?
"As a nurse, I am required by law to report suspected child abuse."
I am unable to discuss this, but I can contact my supervisor to speak with you."
"The provider will be coming to explain the situation."
"I reported the incident to my supervisor who decided to contact the authorities.
The Correct Answer is A
A. This response is clear, professional, and factual. Nurses are mandated reporters and are legally obligated to report any suspicion of child abuse, regardless of confirmation. This statement provides an appropriate explanation without placing blame or making accusations.
B. While involving a supervisor can be helpful, avoiding the question may increase tension and does not clarify the nurse’s legal duty.
C. Deflecting to the provider fails to acknowledge the nurse’s role and responsibility in mandated reporting.
D. This response shifts responsibility and may imply blame or avoid accountability, which is not appropriate or professional.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Preparing the family for imminent death is premature and inappropriate as the first action. Hyper-cyanotic spells (Tet spells) are medical emergencies but often reversible with prompt intervention.
B. CPR is not the first response unless the child is unresponsive and pulseless. Tet spells are managed with specific interventions to reduce hypoxia.
C. Assessing for neurological defects may be important later, but during an acute Tet spell, the priority is to restore oxygenation and stabilize the child.
D. The first action during a Tet spell is to administer oxygen to reduce pulmonary vasoconstriction and improve oxygenation. This is often followed by placing the child in a knee-chest position, giving morphine, and preparing for further medical support as needed. Oxygen is the most immediate, non-invasive intervention.
Correct Answer is C
Explanation
A. The Oucher scale is a self-report pain scale appropriate for children 3 years and older who can point to a face that matches their pain intensity.
B. The FACES scale also relies on self-report and is best suited for children 3 years and older.
C. The FLACC scale (Face, Legs, Activity, Cry, Consolability) is an observational pain assessment tool used for infants and young children who are unable to verbalize their pain, such as a 6-month-old.
D. The Visual Analog Scale requires the child to mark a point on a line to indicate pain intensity and is appropriate for older children and adults.
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