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 B
Explanation
Choice A reason: This statement is incorrect because an interprofessional team does not necessarily decrease the number of visits to client by staff. In fact, an interprofessional team may increase the frequency and quality of communication and interaction between the client and the staff, as each member of the team contributes their expertise and perspective to the client's care. This can enhance the client's satisfaction, engagement, and education.
Choice B reason: This statement is correct because an interprofessional team can improve the efficiency in client care services. An interprofessional team can coordinate and integrate the care delivery across different disciplines, settings, and levels of care, reducing the duplication, fragmentation, or gaps in the services. This can also lower the costs and risks of care, and improve the outcomes and quality of care.
Choice C reason: This statement is incorrect because an interprofessional team does not increase the length of stay for client. On the contrary, an interprofessional team can reduce the length of stay for client by providing timely, appropriate, and effective care that meets the client's needs and goals. This can also prevent the readmission or complication of the client, and facilitate the transition and discharge of the client.
Choice D reason: This statement is incorrect because an interprofessional team does not decrease the number of referrals needed for client. Rather, an interprofessional team can enhance the referral process by ensuring that the client receives the right service from the right provider at the right time. An interprofessional team can also collaborate and communicate with the referral sources, and follow up on the client's progress and response to the service.
Correct Answer is D
Explanation
Choice A reason: The minimum number of items on the exam is 65 is not an information that the nurse should identify about the NCLEX exam. This is a false statement that does not reflect the current format of the exam. According to the NCSBN website, the minimum number of items on the NCLEXRN exam is 75, and the minimum number of items on the NCLEXPN exam is 85.
Choice B reason: The maximum number of items on the exam is 165 is not information that the nurse should identify about the NCLEX exam. This is a false statement that does not reflect the current format of the exam. According to the NCSBN website, the maximum number of items on the NCLEXRN exam is 145, and the maximum number of items on the NCLEXPN exam is 205.
Choice C reason: All 50 states have the same criteria for passing the exam is not an information that the nurse should identify about the NCLEX exam. This is a false statement that does not account for the variations in the passing standards among different jurisdictions. According to the NCSBN website, the passing standard for the NCLEXRN exam is 0.2700 logits, and the passing standard for the NCLEXPN exam is 0.1800 logits. However, some jurisdictions may have additional requirements or criteria for licensure or registration, such as education, background checks, or jurisprudence exams.
Choice D reason: An 80% confidence rule is used for passing the exam is information that the nurse should identify about the NCLEX exam. This is a true statement that describes the statistical method that is used to determine the pass or fail status of the candidates. According to the NCSBN website, the NCLEX exam uses a computerized adaptive testing (CAT) model that adjusts the difficulty and the number of the items based on the candidate's ability. The exam ends when the candidate's ability estimate is either above or below the passing standard with at least 80% confidence, or when the maximum or minimum number of items or time is reached.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.