A nurse is assessing a child and notes several bruises. Which of the following actions should the nurse take?
Ask a psychiatrist to talk with the parents.
Separate the child from the parents.
Report the suspected abuse to the authorities.
Obtain a detailed history.
The Correct Answer is D
a. While involving mental health professionals can be part of a broader intervention plan, it is not the immediate priority in cases of suspected abuse. The nurse must first address the immediate safety concerns and follow the required reporting procedures.
b. Separating the child from the parents without proper authority or immediate threat can escalate the situation and may not be legally permissible. This action should be taken by authorities with the legal power to do so if deemed necessary.
c. Nurses are mandated reporters, which means they are legally required to report any suspected child abuse to the appropriate authorities immediately. This action ensures that the child’s safety is prioritized and that a proper investigation can be initiated however, obtaining a detailed history is the priority.
d. When a nurse observes several bruises on a child, the initial action should be to obtain a detailed history. This step allows the nurse to gather information about the circumstances surrounding the bruises, assess for any potential signs of abuse, and determine the most appropriate course of action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A.Allowing an infant with a cast for DDH to stand in the crib could place undue stress on the hips and may not be safe, depending on the type of cast and the stability of the condition. Most spica casts will not allow the child to stand, walk or bear any weight.
B.Providing a small electronic toy can help stimulate the infant's sensory and cognitive development. At 10 months old, infants are curious and responsive to interactive toys that can engage their senses and promote fine motor skills and cognitive development.
C.Tie colorful latex balloons to the side of the crib.: While colorful objects can be visually stimulating, latex balloons pose a choking hazard if they burst or are chewed on by the infant. It is safer to use other forms of visual stimulation, such as colorful toys or mobiles.
D.Change the infant's diaper as soon as soiling occurs.: While it is essential to keep the infant clean and dry to prevent skin irritation and infection, this action, although necessary, does not directly promote growth and development. It is a basic care measure rather than a developmental strategy.
Correct Answer is ["C","D","E"]
Explanation
The correct answers are C, D, and E.
Choice A rationale: Intact epidermis would not be expected with a partial-thickness burn as the burn extends into the dermis.
Choice B rationale: A dry surface is not characteristic of partial-thickness burns, which typically have a moist surface.
Choice C rationale: Partial-thickness burns are sensitive to touch due to the damage to nerve endings in the dermis.
Choice D rationale: Wound blanches with pressure because the blood vessels are damaged, allowing blanching on pressure.
Choice E rationale: Blisters are a common feature of partial-thickness burns, as the damage to the dermis causes fluid to accumulate.
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