A nurse is caring for a client who received 50,000 units of IV heparin rather than the prescribed 5,000 units. Which of the following actions should the nurse take first?

The correct answer is C. Explain to the child what will happen when the abuse is reported.

This is because the nurse should provide honest and accurate information to the child about the reporting process and the possible outcomes, such as legal actions, investigations, or removal from the home.

This can help the child feel more prepared and less anxious about what will happen next. The nurse should also reassure the child that the abuse is not their fault and that they did the right thing by telling someone.

Choice A is wrong because reassuring the child that no one will be told about the abuse is unethical and illegal.

The nurse has a mandatory duty to report any suspected or confirmed cases of child abuse to the appropriate authorities, such as child protective services or law enforcement. Keeping the abuse a secret can also endanger the child’s safety and well-being, as well as prevent them from receiving the necessary medical and psychological care.

Choice B is wrong because ensuring that multiple nurses are present for the physical examination can increase the child’s fear, embarrassment, or discomfort.

The nurse should minimize the number of people involved in the examination and only include those who are essential for providing care or collecting evidence. The nurse should also explain to the child what will be done during the examination and obtain their consent before proceeding.

Choice D is wrong because using leading statements to obtain information from the child can influence their responses and affect the validity of their testimony.

The nurse should use open-ended questions and avoid suggesting or implying any details about the abuse. The nurse should also document the child’s statements verbatim and avoid interpreting or paraphrasing them.

The correct answer is choice B. Applying an orthotic to the client’s foot.

An orthotic is a device that supports or corrects the function of a body part.

In this case, an orthotic can help prevent foot drop, which is a common contracture deformity in immobile patients.

Foot drop occurs when the muscles that lift the foot become weak or paralyzed, causing the foot to hang down at the ankle. An orthotic can keep the foot in a neutral position and prevent shortening of the calf muscles and Achilles tendon.

Choice A is wrong because a trochanter wedge is used to prevent external rotation of the hip, not contracture. A trochanter wedge is a triangular-shaped pillow that is placed between the legs to keep them parallel and aligned.

Choice C is wrong because a towel roll under the neck is used to maintain proper cervical alignment, not contracture. A towel roll can prevent hyperextension of the neck and support the natural curve of the spine.

Choice D is wrong because a pillow under the knees can actually cause contracture of the knee joint by keeping it in a flexed position. A pillow under the knees can also reduce blood flow to the lower extremities and increase the risk of deep vein thrombosis.

Contracture is a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.

Contracture can limit the range of motion and function of the affected body part. Contracture can be caused by inactivity, scarring, or diseases that affect the muscles or nerves. Prevention of contractures requires early diagnosis and initiation of physical medicine approaches such as passive range of motion exercises and splinting before contractures are present or while contractures are mild.