A nurse is caring for a client and using active listening skills. Which of the following actions should the nurse take?

A.While childhood obesity is a health concern, it is not a specific indicator of abuse. Obesity can result from dietary habits, lack of physical activity, or medical conditions.

B.Fear of injections is common in children and is a typical developmental response. Crying during an injection is not an indicator of abuse and is expected behavior for many children.

C.While this finding alone does not confirm abuse, it may indicate an underlying issue in the adolescent's home environment. It requires further exploration through careful, open-ended questioning to assess for potential emotional or physical abuse or neglect.

D.Bruising on the shins of toddlers is common due to normal play and falls during development. The explanation provided by the parents aligns with typical toddler behavior and does not raise immediate concerns for abuse unless the bruises are in unusual locations (e.g., abdomen, back, or thighs).

Explanation:

A. Arrange referral for family therapy to deal with home stressors:

While family therapy may be beneficial for addressing home stressors, it is not the first step when there is a suspicion of physical abuse. The priority in cases of suspected abuse is to ensure the client's safety and to report the suspicion to the appropriate authorities.

B. Follow the agency's guidelines for reporting suspected abuse:

This is the correct action to take first. Nurses are mandated reporters, and they must follow their agency's protocols and legal requirements for reporting suspected abuse. Reporting ensures that the client's situation is investigated promptly, and appropriate interventions are implemented to protect the client.

C. Check the bruises at the next visit to the client's home:

Delaying action and waiting until the next visit to check the bruises is not appropriate in cases of suspected abuse. Immediate action is necessary to address the safety of the client. Suspected abuse should be reported promptly to the relevant authorities for investigation.

D. Institute more frequent visits to the client's home:

Increasing the frequency of visits may not address the immediate safety concerns of the client if abuse is suspected. While increased monitoring may be necessary in certain situations, reporting the suspicion of abuse and initiating appropriate interventions should take precedence.