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 B
Explanation
Choice A reason:
Hopscotch requires a level of coordination and balance that may be challenging for a 2-year-old toddler.
Choice B reason:
Finger painting is a creative and age-appropriate activity for a 2-year-old. It allows them to explore colors and textures while developing fine motor skills.
Choice C reason:
Beginner sports may involve activities that are too complex for a 2-year-old to fully understand and participate in.
Choice D reason:
A 30-piece puzzle may be too advanced for a 2-year-old. They may have difficulty manipulating the small pieces and understanding the concept of assembling the puzzle.
Correct Answer is A
Explanation
Choice A reason:
Diminished pulses can be indicative of decreased cardiac output, as it suggests that there may be a reduction in the volume of blood being pumped by the heart.
Choice B reason:
Extremities warm to touch is not necessarily indicative of decreased cardiac output. It may be related to other factors, such as ambient temperature or local blood flow.
Choice C reason:
Capillary refill of 2 seconds is within the normal range for a preschooler, and it is not a strong indicator of decreased cardiac output.
Choice D reason:
A blood pressure of 112/66 mm Hg is within the normal range for a preschooler and is not a strong indicator of decreased cardiac output.
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