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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
At 18 months, a toddler should typically be saying more than four words. This finding may
indicate a potential delay in speech development, and it should be reported to the provider for further evaluation.
Choice B reason:
Building a tower of three blocks is an appropriate developmental milestone for an 18-month-old and does not warrant reporting.
Choice C reason:
Temper tantrums are a normal behavior for toddlers, as they are still developing emotional regulation skills. This finding does not require reporting unless it is severe or causing harm to the child.
Choice D reason:
Jumping in place with both feet is an appropriate developmental milestone for an 18-month-old and does not warrant reporting.
Correct Answer is ["C","D","E"]
Explanation
Choice A reason:
Tinnitus - Tinnitus (ringing in the ears) is not typically associated with bacterial meningitis. The focus is on central nervous system symptoms and signs of meningeal irritation.
Choice B reason:
Negative Kernig sign - This is a classic sign of meningeal irritation. In bacterial meningitis, the Kernig sign will be positive, indicating resistance and pain upon extension of the knee after flexing the hip.
Choice C reason:
Vomiting - Nausea and vomiting are common symptoms of bacterial meningitis. They are caused by increased intracranial pressure and meningeal irritation.
Choice D reason:
Headache - Headache is a common symptom of bacterial meningitis, often severe and accompanied by other signs of meningeal irritation.
Choice E reason:
Seizures - Seizures can occur in bacterial meningitis due to the inflammation and irritation of the brain.
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