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?

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.

The correct answer is c. Reacting to the nurse as though she were his mother.

Choice A rationale:

• Refusing to participate in group activities can be a sign of social anxiety,withdrawal,or other mental health issues,but it's not specifically indicative of transference.
• Individuals with personality disorders may withdraw from social interactions for various reasons,such as fear of rejection,discomfort in social settings,or a preference for isolation.
• While refusal to participate in group activities could be a manifestation of transference in some cases,it's not the most typical or defining characteristic.

Choice B rationale:

• Talking negatively about other staff members can occur due to dissatisfaction with treatment,personality traits,or interpersonal conflicts.
• It's not directly related to transference,which involves projecting feelings and expectations from past relationships onto current ones.
• While individuals with personality disorders may engage in negative talk about others,this behavior doesn't necessarily stem from transference.

Choice C rationale:

• Reacting to the nurse as though she were his mother is a classic example of transference.
• In this case,the client is unconsciously transferring feelings,thoughts,and behaviors associated with his mother onto the nurse.
• This can manifest in various ways,such as seeking excessive attention or reassurance from the nurse,becoming overly dependent on her,or reacting with anger or hostility if she doesn't meet his expectations.
• This behavior is a key indicator that the client is using transference as a coping mechanism.

Choice D rationale:

• Expressing frustration regarding unit rules can be a sign of difficulty with authority or adjusting to the structure of a treatment setting.
• It's not inherently a sign of transference,as it doesn't involve projecting feelings from past relationships onto the current one.
• Individuals with personality disorders may struggle with rules and authority,but this behavior is not a direct manifestation of transference.