A nurse in a provider's office is assessing a school-age child who has a spiral fracture. The parent of the child provides different accounts of the cause of the injury. Which of the following actions should the nurse take first?
Report suspected abuse to Child Protective Services.
Determine the immediate safety needs of the child.
Ask the child how the injury occurred.
Request that the parent leave the room while interviewing the child.
The Correct Answer is B
The nurse's priority is to ensure that the child is safe and protected from further harm. A spiral fracture is a type of fracture that occurs when a bone is twisted, and it is often associated with child abuse. The nurse should assess if there are any other signs of abuse, such as bruises, burns, or cuts, and if there are any threats to the child's well-being at home or elsewhere. The nurse should also provide emotional support and comfort to the child. The other options are important steps to take, but they are not as urgent as ensuring safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
During the orientation phase, the nurse should introduce herself and the group members, explain the purpose and goals of the group, and create a trusting and respectful atmosphere. Maintaining focus, encouraging problem-solving, and managing conflict are actions that belong to the working phase of group development.
Correct Answer is C
Explanation
A. Weigh the client every other day – Frequent weighing can increase the client’s focus on weight, potentially adding stress and anxiety, which is not beneficial for managing binge eating disorder.
B. Plan a menu with the client – Although planning meals can be helpful, remaining with the client after meals is more directly aimed at preventing bingeing behaviors.
C. Remain with the client for 1 hr after meals – Staying with the client after meals helps to monitor for any signs of binge eating behavior and provides support, reducing the likelihood of excessive eating episodes.
D. Offer snacks when the client is hungry – Unstructured snacking can promote impulsive eating and does not assist the client in establishing controlled eating patterns.
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