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 D
Explanation
Choice A reason: This statement is false and should not be included in the educational session. TJC is not a for profit organization, but rather an independent, not-for-profit organization that accredits and certifies more than 21,000 health care organizations and programs in the United States.
Choice B reason: This statement is false and should not be included in the educational session. TJC is not an organization that monitors insurance claims, but rather an organization that evaluates health care organizations and inspires them to excel in providing safe and effective care of the highest quality and value.
Choice C reason: This statement is false and should not be included in the educational session. TJC does not provide licensure for health care providers, but rather accreditation and certification for health care organizations and programs. Licensure is the process by which a governmental authority grants permission to individuals or entities to engage in a regulated activity or profession.
Choice D reason: This statement is true and should be included in the educational session. TJC provides accreditation to facilities, which is a voluntary process that involves an external review of an organization's compliance with certain standards and criteria. Accreditation is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards.
Correct Answer is D
Explanation
Choice A reason: Outside client's room is not an appropriate area to provide report to the oncoming nurse. This area may not be private or quiet enough to ensure confidentiality and accuracy of the information. The nurse may also miss important cues or changes in the client's condition or environment.
Choice B reason: Conference area is not an appropriate area to provide report to the oncoming nurse. This area may be too far from the client's room or the nursing station, which can delay the response time or the continuity of care. The nurse may also lose the opportunity to interact with the client and the family, and to verify the data with the physical assessment.
Choice C reason: Nurse's lounge is not an appropriate area to provide report to the oncoming nurse. This area may be too informal or distracting to maintain the professionalism and focus of the report. The nurse may also violate the privacy and dignity of the client and the family by discussing their personal or medical information in a public place.
Choice D reason: Client's bedside is an appropriate area to provide report to the oncoming nurse. This area allows the nurse to involve the client and the family in the report, which can enhance their satisfaction, safety, and education. The nurse can also observe the client's condition and behavior, and perform the physical assessment and the medication reconciliation with the oncoming nurse.
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