A nurse on a medical-surgical unit is caring for a group of children. Which of the following findings should alert the nurse that one of the children is a potential victim of abuse?

Explanation:

A. Arrange referral for family therapy to deal with home stressors:

While family therapy may be beneficial for addressing home stressors, it is not the first step when there is a suspicion of physical abuse. The priority in cases of suspected abuse is to ensure the client's safety and to report the suspicion to the appropriate authorities.

B. Follow the agency's guidelines for reporting suspected abuse:

This is the correct action to take first. Nurses are mandated reporters, and they must follow their agency's protocols and legal requirements for reporting suspected abuse. Reporting ensures that the client's situation is investigated promptly, and appropriate interventions are implemented to protect the client.

C. Check the bruises at the next visit to the client's home:

Delaying action and waiting until the next visit to check the bruises is not appropriate in cases of suspected abuse. Immediate action is necessary to address the safety of the client. Suspected abuse should be reported promptly to the relevant authorities for investigation.

D. Institute more frequent visits to the client's home:

Increasing the frequency of visits may not address the immediate safety concerns of the client if abuse is suspected. While increased monitoring may be necessary in certain situations, reporting the suspicion of abuse and initiating appropriate interventions should take precedence.

Explanation:

A. Bathtub with rails:

Having a bathtub with rails is generally considered a safety measure, as it can assist the client in safely entering and exiting the bathtub. Rails provide support and stability, especially for older adults who may have mobility issues. Therefore, this finding is not typically identified as a safety risk.

B. Raised toilet seats:

Raised toilet seats can also be beneficial for older adults with mobility challenges, as they make it easier to sit down and stand up from the toilet. Similar to bathtub rails, raised toilet seats are considered a safety measure rather than a safety risk.

C. Electric cords behind furniture:

Electric cords behind furniture pose a tripping hazard, especially for older adults who may have reduced balance or vision. Trips and falls can lead to serious injuries, so it's important to keep walkways clear of obstacles, including electric cords. Therefore, this finding is identified as a safety risk.

D. Water heater temperature 54.4°C (130° F):

The recommended safe water heater temperature to prevent scalding injuries is typically around 48.9°C (120°F). A water heater temperature of 54.4°C (130°F) is higher than the recommended safe range and can increase the risk of scalding injuries, especially for older adults with sensitive skin or reduced sensation. Therefore, this finding is identified as a safety risk.

E. Throw rugs:

Throw rugs are common tripping hazards, particularly if they are not secured to the floor or have curled edges. Older adults can easily trip on throw rugs, leading to falls and injuries. It's recommended to remove or secure throw rugs to reduce the risk of falls, making this finding a safety risk.