A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse?

• Out of the provided options, the most important information for the nurse to include in the change-of-shift report is:

  c. The time of the client's last dose of pain medication

  Here's why:

• a. The frequency in which the client presses the call button:While this could be relevant to assess the client's overall well-being or potential anxiety, it's not as crucial as pain management in this specific scenario.
• b. The client's most recent ventilator settings:Since the client is already weaned from ventilation, this information is no longer pertinent.
• d. The last time the provider evaluated the client:While provider updates are important, especially after major procedures like a pneumonectomy, knowing the exact timing isn't as critical as pain management, especially considering the potential for increased pain after surgery and weaning from ventilation.
• c. The time of the client's last dose of pain medication:Pain management is paramount after a pneumonectomy. Knowing the timing of the last dose allows the receiving nurse to assess the need for further medication and potential for breakthrough pain management. Additionally, it provides a baseline for monitoring pain trends and potential complications related to pain, such as decreased mobility or respiratory compromise.

• Therefore, while all the information listed could be relevant at some point, knowing the time of the last pain medication dose is the most crucial for immediate patient care and should be prioritized in the change-of-shift report for a post-pneumonectomy client transitioning from ICU to the medical floor.

Choice A rationale:

Documenting the client's vital signs obtained by an assistive personnel is correct. Documenting vital signs is fundamental and immediate requirement when admitting a client to ensure their current health status is accurately captured and can be monitored effectively.

Choice B rationale:

Charting a summary of the data at the change of the shift is incorrect. While it's essential to provide an update at shift change, this option suggests summarizing the data, which might not include all necessary details. Comprehensive documentation is crucial for continuity of care and accurate communication among healthcare providers. Documenting specific vital signs, assessments, interventions, and the client's response to those interventions is necessary for effective patient care.

Choice C rationale:

Noting whether the client has a living will is incorrect. While it's essential to be aware of a client's advanced directives, this information is typically gathered during the admission process or during routine assessments. It is not the immediate action to be taken upon admission. Vital signs and other immediate clinical data take precedence during the initial documentation process.

Choice D rationale:

Beginning charting with an evaluation of the data is incorrect. It is important to document objective data, such as vital signs, observations, and assessments, before making any evaluations or interpretations. Objective data provide the basis for clinical decisions and interventions. Starting with evaluations might lead to biased documentation, potentially overlooking important clinical findings.