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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The priority for the nurse is to assess the client's safety and risk of self-harm or suicide, which may increase during a situational crisis. The other questions are also important to explore, but they are not as urgent as assessing for suicidal ideation or intent.

A. Significant weight loss B. Markedly neglected hygiene C. Psychomotor retardation D. Poor problem-solving skills

Correct Answer is A

Explanation

Choice A reason:

Significant weight loss in a patient with major depressive disorder is a red flag for clinicians. It can signify a high risk of complications, including malnutrition, electrolyte imbalance, and weakened immunity. In the context of depression, it may also reflect a lack of self-care or even suicidal tendencies, which require immediate attention.

Choice B reason:

While markedly neglected hygiene is concerning and indicative of a patient's inability to perform daily self-care activities, it is not typically considered an immediate life-threatening issue. However, it does warrant intervention to prevent potential secondary infections or complications.

Choice C reason:

Psychomotor retardation is a symptom that can manifest in major depressive disorder, characterized by slowed physical movements and cognitive processing. Although it impacts the quality of life and daily functioning, it is not usually a direct indicator of an acute life-threatening condition.

Choice D reason:

Poor problem-solving skills are part of the cognitive symptoms of depression, affecting a patient's ability to manage daily tasks and make decisions. While this can significantly impact a patient's life, it is not as urgent as significant weight loss, which can have immediate physical health consequences.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is A

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