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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Home care is the most appropriate resource referral for this client, as they will need skilled nursing care to perform wound care and monitor the healing process. Home care can also provide education and support for the client and their family.

Choice B reason: Assisted living is not a suitable resource referral for this client, as they do not provide skilled nursing care or wound care. Assisted living facilities are designed for clients who need assistance with activities of daily living, but not medical care.

Choice C reason: Long-term care is not a necessary resource referral for this client, as they do not have a chronic or terminal condition that requires 24hour nursing care. Long-term care facilities are intended for clients who are unable to live independently due to physical or cognitive impairments.

Choice D reason: Hospice care is not an appropriate resource referral for this client, as they do not have a terminal illness or a life expectancy of less than six months. Hospice care provides palliative care and comfort measures for clients who are dying and their families.

A. "Acute care will not treat my child's illness. We can leave our child and perform our personal errands." B. "We will take our child home and wait for the nurse to come." C. "My child will be at this facility for at least a month." D. "My child will receive medications to manage their condition."

Correct Answer is D

Explanation

Choice A reason: This statement does not indicate an understanding of acute care, but rather a misconception and a lack of responsibility. Acute care is a level of health care that provides immediate and short-term treatment for severe or life-threatening conditions, such as asthma attacks. Acute care requires the parents to stay with their child and participate in their care plan.

Choice B reason: This statement does not indicate an understanding of acute care, but rather a denial and a delay of treatment. Acute care is not provided at home, but at a specialized facility that has the equipment and staff to handle emergencies. Waiting for the nurse to come may worsen the child's condition and increase the risk of complications.

Choice C reason: This statement does not indicate an understanding of acute care, but rather an exaggeration and a misunderstanding of the duration of treatment. Acute care is not meant to last for a long time, but only until the condition is stabilized or resolved. The length of stay at an acute care facility depends on the severity of the condition and the response to treatment, but it is usually less than a month.

Choice D reason: This statement indicates an understanding of acute care, as it reflects the main goal and intervention of acute care for asthma. Acute care for asthma involves administering medications that can quickly relieve the symptoms and prevent further inflammation of the airways. Medications may include bronchodilators, corticosteroids, oxygen, and others.

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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?

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