During a home health visit, a school-age child who has muscular dystrophy confides in the nurse that he was struck by his parents. Which of the following actions should the nurse take first?
Report the incident to local authorities
Check the child for injuries
Refer the parent to a social service agency
Enroll the parent in anger management classes
The Correct Answer is B
Choice A reason: Reporting the incident to local authorities is an important action, but it is not the first priority. The nurse should first assess the child's physical condition and provide any necessary care.
Choice B reason: Checking the child for injuries is the first action the nurse should take, as the child may have sustained physical harm from the abuse. The nurse should document any findings and report them to the appropriate authorities.
Choice C reason: Referring the parent to a social service agency is a helpful action, but it is not the first priority. The nurse should first ensure the child's safety and well-being.
Choice D reason: Enrolling the parent in anger management classes is a potential intervention, but it is not the first priority. The nurse should first address the immediate needs of the child and the family.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Collecting data to identify barriers to learning is the first action that the nurse should take. This is based on the principle of assessment, which states that the nurse should gather information about the needs, interests, and characteristics of the target population before planning any intervention. The nurse should assess the barriers that may prevent the adolescents from participating in or benefiting from the program, such as lack of knowledge, motivation, access, or support.
Choice B reason: Establishing methods to evaluate program outcomes is not the first action that the nurse should take. This is based on the principle of evaluation, which states that the nurse should measure the effectiveness and impact of the intervention after implementing it. The nurse should determine the criteria and indicators that will be used to evaluate the program outcomes, such as changes in knowledge, attitudes, behaviors, or health status.
Choice C reason: Obtaining visual aids that feature adolescents is not the first action that the nurse should take. This is based on the principle of implementation, which states that the nurse should deliver the intervention using appropriate strategies and resources. The nurse should obtain visual aids that are relevant, accurate, and appealing to the adolescents, and that can enhance the learning process and the message delivery.
Choice D reason: Providing computer-based education is not the first action that the nurse should take. This is based on the principle of implementation, which states that the nurse should deliver the intervention using appropriate strategies and resources. The nurse should provide computer-based education if it is feasible, accessible, and preferred by the adolescents, and if it can facilitate the learning objectives and outcomes.
Correct Answer is B
Explanation
Choice A reason: Creating diversionary activities for children is not the priority action for the nurse to take. This is a supportive intervention that can help the children cope with the stress and trauma of the disaster, but it should be done after the nurse has ensured the safety and well-being of the clients.
Choice B reason: Addressing the physical needs of clients is the priority action for the nurse to take. This is based on the principle of Maslow's hierarchy of needs, which states that the nurse should prioritize the most basic and essential needs of the clients, such as food, water, shelter, clothing, and medical care. The nurse should assess the clients for any injuries, illnesses, or chronic conditions, and provide appropriate interventions or referrals.
Choice C reason: Helping clients gather needed supplies is not the priority action for the nurse to take. This is a helpful intervention that can assist the clients to obtain the resources and materials they need to survive and recover from the disaster, but it should be done after the nurse has addressed the physical needs of the clients.
Choice D reason: Exploring feelings the clients are experiencing is not the priority action for the nurse to take. This is a therapeutic intervention that can facilitate the emotional and psychological healing of the clients, but it should be done after the nurse has addressed the physical needs of the clients. The nurse should also respect the clients' readiness and willingness to share their feelings, and avoid forcing or rushing the process.
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