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. Re-collection of data:

This step involves gathering additional information or data about the client's condition. It may be necessary if there are new developments, changes in the client's status, or if the initial data collected was insufficient or inaccurate. Re-collection of data helps ensure that the nurse has comprehensive and accurate information to base the care plan on.

B. Implementation:

Implementation is the phase where the nurse puts the planned interventions into action. This step involves performing nursing actions, administering treatments or medications, providing education and support to the client and their family, and collaborating with other healthcare team members. The nurse follows the care plan developed during the planning phase to address the client's needs and achieve desired outcomes.

C. Evaluation:

Evaluation is the final step of the nursing process where the nurse assesses the client's response to interventions and the effectiveness of the care provided. The nurse compares the client's actual outcomes with the expected outcomes identified during the planning phase. If the outcomes are met, the plan may continue as is or be modified for ongoing care. If the outcomes are not met, the nurse revises the plan as necessary to improve client outcomes.

D. Data Collection:

Data collection is the initial step of the nursing process where the nurse gathers information about the client's health status, including physical, emotional, social, and environmental factors. This step involves conducting assessments, gathering medical history, reviewing laboratory and diagnostic tests, and obtaining information from the client and their family. Data collection forms the basis for identifying nursing diagnoses, developing care plans, and implementing appropriate interventions.

Explanation:

A. Right communication:

This refers to providing clear and concise instructions to the assistive personnel regarding the delegated task. Effective communication ensures that the AP understands the task, its objectives, any limitations or special considerations, and the expectations regarding its completion. Clear communication helps prevent misunderstandings and promotes safe and efficient task execution.

B. Right room:

This choice does not directly relate to the five rights of delegation. The "right room" concept may refer to ensuring that the environment or room where care is provided is appropriate, safe, and conducive to the task being performed. While environmental factors are important in healthcare, they are not part of the specific rights of delegation.

C. Right time:

The "right time" aspect of delegation involves considering the timing of the task within the overall care plan. It includes assessing whether the task should be performed immediately, at a specific time, or within a particular timeframe. Delegating tasks at the right time ensures that they align with the client's needs and the overall care schedule.

D. Right documentation:

This refers to documenting the delegation process, including details such as the delegated task, the personnel involved, any specific instructions or limitations provided, and the outcomes or results of the task. Documentation is crucial for accountability, continuity of care, and legal purposes, ensuring that there is a record of who performed the task and how it was carried out.