What is the most important factor for the nurse to assess when doing an admission assessment of a client with a history of alcoholism?

a. Several visits of the same child with varied injuries.

Explanation of Choices

Choice A Reason: Several Visits of the Same Child with Varied Injuries

This scenario raises the highest suspicion of child abuse. Multiple visits with different injuries can indicate a pattern of harm rather than isolated accidents. Healthcare providers are trained to recognize that varied injuries over time, especially in different stages of healing, can be a red flag for abuse. This pattern suggests that the child may be experiencing ongoing harm rather than a single incident. The nurse should conduct a thorough assessment and consider involving child protective services to ensure the child’s safety.

Choice B Reason: A 5-Year-Old Child Who Broke His Arm and Clings to Mother Crying

While a broken arm in a child can be concerning, it is not uncommon for children to sustain such injuries during play or accidents. The child’s emotional response of clinging to the mother and crying is also typical for a young child in pain and distress. This scenario alone does not strongly indicate abuse without additional context or evidence. However, the nurse should still assess the situation carefully and consider any other signs or patterns that might suggest abuse.

Choice C Reason: A 1-Year-Old Child Who Has a Dislocated Shoulder from Arm Swinging

A dislocated shoulder in a 1-year-old is unusual and can be concerning. While it could result from an accident, such as arm swinging, it is also a potential sign of abuse, especially if the explanation does not match the injury. The nurse should investigate further, considering the child’s medical history and any other signs of potential abuse. However, this scenario alone does not provide as strong an indication of abuse as multiple varied injuries.

Choice D Reason: Repeated Visits of the Same Child with Middle Ear Infections

Repeated visits for middle ear infections are common in young children and are typically related to medical issues rather than abuse. Middle ear infections can occur frequently in children due to their anatomy and immune system development. This scenario does not raise immediate concerns about abuse unless there are other signs or patterns of harm. The nurse should focus on providing appropriate medical care and monitoring the child’s health.

Choice A Reason:

Promoting activities that encourage self-reflection. While promoting self-reflection is important in the therapeutic process, it is not the most essential aspect initially for establishing a trusting nurse-patient relationship. Self-reflection activities are more effective once a foundation of trust has been established.

Choice B Reason:

Conveying an accepting attitude. This statement is correct. Conveying an accepting attitude is crucial in the initial stages of establishing a trusting nurse-patient relationship. Patients with borderline personality disorder often feel judged and misunderstood. An accepting attitude helps to create a safe and supportive environment, which is essential for building trust and encouraging open communication.

Choice C Reason:

Identifying community resources. Identifying community resources is important for long-term support and management of borderline personality disorder, but it is not the most essential aspect initially for establishing trust. This step is more relevant once the therapeutic relationship has been established and the patient is ready to engage with external support systems.

Choice D Reason:

Providing positive feedback. Providing positive feedback is beneficial in reinforcing positive behaviors and encouraging progress. However, it is not the most essential aspect initially for establishing trust. Positive feedback is more effective when the patient already feels understood and supported by the nurse.