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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Normal urine output for a child is 1-2 ml/kg/hr.
The child weighs 33 lb (15 kg), so their expected urine output over an 8-hour period would be between 120 mL and 240 mL.
The child’s urine output of 160 mL falls within this range.
Choice A, Notifying the provider, is not necessary because the child’s urine output
is within the normal range.
Choice C, Perform a bladder scan at the bedside, is not necessary because there is no indication of urinary retention.
Choice D, Providing oral rehydration ﬂuids, is not necessary because the child’s urine output is within the normal range.

A. Feelings of isolation. B. Frequent nosebleeds. C. Back pain. D. Itching of skin.

Correct Answer is A

Explanation

Isotretinoin has been associated with depression and other psychiatric side eﬀects.
The client should report any changes in mood or behavior, including feelings of isolation, to the provider immediately.
Choice B is not an answer because while frequent nosebleeds can be a side
eﬀect of isotretinoin, it is not the priority to report to the provider.
Choice C is not an answer because while back pain can be a side eﬀect of isotretinoin, it is not the priority to report to the provider.
Choice D is not an answer because while itching of the skin can be a side eﬀect of isotretinoin, it is not the priority to report to the provider.

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A nurse is assessing a child and notes several bruises. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 3-year-old child who has had 160 mL of urine output over the past 8-hour period. The child weighs 33 lb. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is providing teaching to a 17-year-old female client who has severe acne about the use of isotretinoin. Which of the following adverse eﬀects should the nurse instruct the client is the priority to report to the provider?

Correct Answer is A

Explanation

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