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 D
Explanation
Choice A reason: This statement is false and should not be included in the teaching. The Enforcement Rule does not address the use and disclosure of ePHI, which stands for electronic protected health information. The use and disclosure of ePHI is addressed by the Privacy Rule and the Security Rule, which are part of the HIPAA Administrative Simplification Rules.
Choice B reason: This statement is false and should not be included in the teaching. The Enforcement Rule does not cover the process of reporting data breaches, which are unauthorized or unlawful access, use, or disclosure of protected health information. The process of reporting data breaches is covered by the Breach Notification Rule, which is also part of the HIPAA Administrative Simplification Rules.
Choice C reason:This statement is false and should not be included in the teaching.The definition of protected health information (PHI) is outlined in the HIPAA Privacy Rule, not the Enforcement Rule. PHI includes any information about health status, provision of healthcare, or payment for healthcare that can be linked to an individual, whether in electronic, paper, or oral form. The Privacy Rule defines PHI and ePHI explicitly to establish what needs to be protected under HIPAA regulations. The Enforcement Rule does not define PHI but instead deals with the penalties and compliance actions when HIPAA rules, such as those defined in the Privacy or Security Rules, are violated.
Choice D reason:This statement is true and should be included in the teaching. The HIPAA Enforcement Rule explicitly covers the administration of financial penalties for violations of HIPAA regulations. It outlines the processes by which the Department of Health and Human Services (HHS) investigates potential violations, determines compliance failures, and imposes civil monetary penalties when necessary. The Enforcement Rule also establishes the structure of penalties based on factors such as the severity of the violation, whether the violation was willful or accidental, and whether corrective actions were taken promptly. This ensures accountability and compliance with HIPAA standards, making this the correct answer to the question.
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