A nurse in an urgent care clinic is caring for a school-age child who has injuries resulting from physical maltreatment. Which of the following actions should the nurse take first?
Ensure the child's safety.
Tell the child they are not at fault.
Document the location of the child’s injuries
Notify local law enforcement.
The Correct Answer is A
Choice A reason:
Ensuring the child's safety is the top priority. If the child is in immediate danger, steps must be taken to protect them.
Choice B reason:
While providing emotional support to the child is important, ensuring their physical safety takes precedence.
Choice C reason:
Documenting injuries is important for a comprehensive assessment and for legal purposes, but it should follow ensuring the child's immediate safety.
Choice D reason:
Notifying law enforcement may be necessary, but ensuring the child's immediate safety comes first.
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Correct Answer is D
Explanation
Choice A reason:
Avoiding discussing the child's diagnosis with the sibling may create unnecessary secrecy and could hinder the sibling's understanding and coping.
Choice B reason:
Designating one parent to stay at home with the sibling may not be necessary, as both parents can still provide support and care for both children.
Choice C reason:
Avoiding having the sibling visit the child in the facility may isolate them and prevent opportunities for bonding and support.
Choice D reason:
This statement is correct. Encouraging phone calls between the siblings allows them to maintain communication, express their feelings, and support each other during the separation caused by hospitalization.
Correct Answer is B
Explanation
Choice A reason:
Administering iron dextran subcutaneously into the vastus lateralis is not the recommended route for this medication. It is typically administered intramuscularly.
Choice B reason:
Correct. The preferred method for administering iron dextran is intramuscularly using the Z-track method. This technique helps prevent leakage of the medication into the subcutaneous tissue.
Choice C reason:
Administering iron dextran subcutaneously into the deltoid is not the preferred route for this medication. It is typically administered intramuscularly.
Choice D reason:
While a 20-gauge needle may be appropriate for intramuscular injections, the Z-track method is the preferred technique for administering iron dextran intramuscularly. The gauge of the needle may vary depending on the specific circumstances and patient characteristics.
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