A nurse is assessing a client who had a stroke 2 days ago. Which of the following findings should the nurse identify as a need for a referral to speech-language pathology?

Choice A reason: Taking pictures of the child's injuries once the parent leaves the room is not a correct action, as it violates the child's privacy and dignity. The nurse should not take pictures of the child without the parent's consent and only if it is required by the facility's policy or the law.

Choice B reason: Having a facility security officer interview the parent is not a correct action, as it is not within the scope of the security officer's role and may escalate the situation. The nurse should not involve the security officer unless there is a threat of violence or harm to the child, the parent, or the staff.

Choice C reason: Completing an incident report concerning the child's injuries is not a correct action, as it is not relevant to the child's situation. The nurse should complete an incident report only if there is an adverse event or error that occurred within the facility that affected the child's care or safety.

Choice D reason: Reporting the child's injuries to Child Protective Services is the correct action, as it is the nurse's legal and ethical duty to protect the child from potential abuse or neglect. The nurse should suspect child abuse based on the child's injuries, which are inconsistent with the parent's explanation and indicative of non-accidental trauma. The nurse should follow the facility's protocol and the state's law for reporting suspected child abuse.

Choice A reason: This is not the information that the nurse should include in the change-of-shift report. The time the client received his last dose of pain medication is not relevant to the transfer to the rehabilitation facility. The nurse should document the pain medication administration in the medication record and communicate it to the receiving nurse.

Choice B reason: This is the information that the nurse should include in the change-of-shift report. The steps to follow when providing wound care are important to ensure the continuity and quality of care for the client. The nurse should explain the type, location, and condition of the wound, the dressing materials and frequency, and any signs of infection or complications.

Choice C reason: This is not the information that the nurse should include in the change-of-shift report. The client's preferred time for bathing is not essential to the transfer to the rehabilitation facility. The nurse should respect the client's preferences and routines, but they are not a priority for the report.

Choice D reason: This is not the information that the nurse should include in the change-of-shift report. The belief that the client has a difficult relationship with his son is not based on facts and may be biased or inaccurate. The nurse should avoid making assumptions or judgments about the client's family dynamics and focus on the objective data and the client's needs.