A nurse is collecting data from a child and notes the presence of bruises on her arms and legs. Which of the following actions should the nurse take first?
Obtain a detailed history.
Report the suspected abuse to the authorities.
Request a social services referral.
Tell the child what will happen to her when the abuse is reported.
The Correct Answer is A
Choice A reason: Obtaining a detailed history is the first action that the nurse should take. History can help the nurse determine the cause, frequency, and severity of the bruises, as well as the child's relationship with the abuser and the risk of further harm. History can also help the nurse assess the child's physical and emotional state, and provide evidence for reporting the abuse later.
Choice B reason: Reporting the suspected abuse to the authorities is not the first action that the nurse should take. The nurse should report the abuse only after obtaining a history and confirming the suspicion. Reporting the abuse prematurely can jeopardize the child's safety and the nurse's credibility. The nurse should also follow the legal and ethical guidelines for reporting abuse in their jurisdiction.
Choice C reason: Requesting a social services referral is not the first action that the nurse should take. The nurse should request a social services referral only after reporting the abuse and ensuring the child's protection. A social services referral can help the child access resources and support, such as counseling, legal aid, foster care, etc. The nurse should also collaborate with the social worker and other members of the interdisciplinary team to provide holistic care for the child.
Choice D reason: Telling the child what will happen to her when the abuse is reported is not the first action that the nurse should take. The nurse should tell the child what will happen to her only after obtaining a history and reporting the abuse. The nurse should also use age-appropriate language and reassure the child that the abuse is not her fault and that she is not alone. The nurse should avoid making promises that they cannot keep, such as saying that the abuser will never hurt her again.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct answer. Disease prevention involves activities and measures taken to reduce the occurrence and impact of specific diseases. In this scenario, the nurse is performing a blood pressure screening for a client with a family history of hypertension. This screening is a preventive measure aimed at detecting and preventing the development of hypertension, which falls under the category of disease prevention. By identifying clients at risk, healthcare providers can intervene early and implement strategies to prevent or manage the condition.
Choice B reason: This is incorrect. Health education involves providing information and knowledge to clients to help them make informed decisions about their health. It focuses on teaching individuals about health-related topics. In this scenario, the nurse is not engaged in health education but rather in blood pressure screening, which is a form of health assessment and monitoring.
Choice C reason: This is incorrect. Health promotion involves activities that encourage and empower individuals to take control of their health and well-being. It aims to enhance the overall health of the population. While blood pressure screening is a preventive measure, it does not encompass the broader concept of health promotion. It is more specific to early detection and monitoring of health conditions.
Choice D reason: This is incorrect. Holistic health refers to an approach that considers the physical, emotional, social, and spiritual aspects of an individual's well-being. It recognizes the interconnectedness of these aspects and seeks to address them in a comprehensive manner. Performing a blood pressure screening, while important, is a specific health assessment task and does not fully encompass the holistic health approach.
Correct Answer is C
Explanation
The correct answer is: c. Less time for direct client care
Choice A: Decreased amount of paperwork
Reason: One of the advantages of electronic charting is that it significantly reduces the amount of paperwork. Traditional paper records require extensive manual documentation, which can be time-consuming and prone to errors. Electronic systems streamline this process, making it easier to input and retrieve patient information. Therefore, decreased paperwork is a benefit, not a challenge.
Choice B: Increased number of medication errors
Reason: Electronic charting systems are designed to reduce medication errors by providing features such as electronic prescribing, automated alerts for potential drug interactions, and barcode scanning for medication administration. These systems help ensure that the right medication is given to the right patient at the right time, thereby decreasing the likelihood of errors. Hence, increased medication errors are not typically associated with electronic charting.
Choice C: Less time for direct client care
Reason: One of the significant challenges of electronic charting is that it can be time-consuming, requiring nurses to spend a considerable amount of time on documentation. This can reduce the time available for direct patient care. Nurses often report that the demands of electronic documentation can detract from their ability to engage with patients, perform assessments, and provide hands-on care.
Choice D: Provides evidence of care provided
Reason: Providing evidence of care is a benefit of electronic charting, not a challenge. Electronic health records (EHRs) create a detailed and accurate record of the care provided, which can be easily accessed and reviewed. This documentation is crucial for legal, regulatory, and quality improvement purposes. Therefore, this option does not represent a challenge.
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