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.

Request that the parent leave the room while interviewing the child.

Determine the immediate safety needs of the child.

Ask the child how the injury occurred.

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C: Determine the immediate safety needs of the child.

Choice A rationale: Reporting suspected abuse to Child Protective Services is an important step in cases of suspected child abuse. However, before taking this action, it is crucial to ensure the immediate safety and well-being of the child. Jumping directly to reporting without assessing the immediate safety needs could potentially put the child at further risk if they are left in a dangerous situation. Therefore, while reporting suspected abuse is necessary, it is not the first action the nurse should take in this scenario.

Choice B rationale: Requesting that the parent leave the room while interviewing the child may be necessary to ensure the child feels comfortable and able to speak freely. However, before conducting the interview, it is essential to address any immediate safety concerns. Additionally, removing the parent from the room may not always be feasible or appropriate, especially if the child requires immediate medical attention or protection. Therefore, while this action may be taken at some point, it is not the first action the nurse should take.

Choice C rationale: Determining the immediate safety needs of the child is the first and most critical action the nurse should take in this scenario. This involves assessing the severity of the injury, evaluating if the child is in immediate danger, and taking any necessary steps to ensure their safety and well-being. This could include providing medical treatment, removing the child from a dangerous environment, or contacting emergency services if needed. By addressing the immediate safety needs first, the nurse can ensure the child's well-being before further investigating the situation.

Choice D rationale: Asking the child how the injury occurred is an important step in gathering information about the incident. However, before conducting the interview, it is essential to prioritize the child's safety and well-being. Jumping directly to questioning without assessing the immediate safety needs could potentially further traumatize the child or put them at risk if they are in a dangerous situation. Therefore, while interviewing the child is necessary, it should not be the first action taken by the nurse.

In conclusion, Choice C, determining the immediate safety needs of the child, is the first action the nurse should take in this scenario to ensure the child's well-being and safety are prioritized.

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Correct Answer is D

No explanation

A. "Lots of people feel ashamed to tell their secrets." B. "You will feel better if you tell me what you did last night." C. "Let's discuss what you feel embarrassed about." D. "You shouldn't feel embarrassed to talk to me."

Correct Answer is C

Explanation

Choice A rationale:

While it's true that many people feel ashamed to tell their secrets, this response does not actively encourage the client to open up about their feelings. It acknowledges the feeling but does not promote a therapeutic conversation.

Choice B rationale:

Encouraging the client to tell the nurse what they did might not be the most appropriate response. The client might not be ready to disclose their actions and pushing them to do so could lead to further distress. It's important to establish trust and create a safe space for the client before delving into specific details.

Choice C rationale:

The correct choice. This response is empathetic and supportive while also gently encouraging the client to discuss their feelings. It opens the door for the client to share at their own pace and lets them know that the nurse is willing to listen without judgment.

Choice D rationale:

While it's true that the client shouldn't feel embarrassed to talk to the nurse, this response doesn't actively address the client's feelings or concerns. It's more important to provide a response that acknowledges the client's emotions and invites open communication.

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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

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