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 C
Explanation
Activated charcoal should be given as soon as possible to help absorb the acetylsalicylic acid in the gastrointestinal tract.
Choice A is not an answer because N-acetylcysteine is used to treat acetaminophen overdose, not acetylsalicylic acid overdose.
Choice B is not an answer because chelation therapy with deferoxamine is used to treat iron poisoning, not acetylsalicylic acid overdose.
Choice D is not an answer because inducing vomiting with syrup of ipecac is no longer recommended for the treatment of poisoning due to the potential for harm and lack of evidence of benefit.
Correct Answer is A
Explanation
Nursing care planning goals for a child with acute glomerulonephritis are directed toward the excretion of excess fluid through urination.
Monitoring fluid status is very important and daily weights are an effective way to monitor fluid retention, as weight gain is the earliest sign of fluid retention.
Choice B, Educating the parents about potential complications, is important but not the nurse’s priority.
Choice C, Place the child on a no-salt-added diet, which may be part of the treatment
plan but is not the nurse’s priority.
Choice D, Maintaining a saline lock, may be necessary for administering medications but is not the nurse’s priority.
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