The nurse in the Emergency Department is taking a history from a family accompanying a child with traumatic injuries that are suspicious for abuse. Which of the following actions is most appropriate for the nurse to take?
Avoid responding to hints that abuse has occurred.
Separate the family from the child during the interview.
Report the concern for potential abuse to the immediate supervisor.
Obtain information as covertly as possible.
The Correct Answer is B
Rationale:
A. Avoid responding to hints that abuse has occurred is not appropriate. The nurse should address and assess any signs or suspicions of abuse openly.
B. Separate the family from the child during the interview is appropriate as it allows the nurse to obtain information from the child without potential coercion or influence from the family members.
C. Report the concern for potential abuse to the immediate supervisor is important but should be done after gathering sufficient information. The immediate action should focus on separating and interviewing the child.
D. Obtain information as covertly as possible is not ideal. It is important to obtain accurate information while ensuring the safety and comfort of the child, rather than being covert.
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Correct Answer is D
Explanation
Rationale:
A. Bruises from a sports injury are less likely to indicate intimate partner violence without additional context.
B. Stress from work is a general issue and does not directly suggest intimate partner violence.
C. A fall down the stairs could be an accident; however, further context is needed to assess if this is related to violence.
D. Fear at home and reluctance to discuss it could indicate underlying intimate partner violence, requiring further assessment and intervention.
Correct Answer is A
Explanation
Rationale:
A. Checking with the doctor ensures that the herbal tea does not interact with the client's medications and is safe for their specific health condition. This response shows concern for the client's safety and adheres to clinical guidelines.
B. Filling out forms is not relevant or necessary for this situation; ensuring safety and medical compatibility is more appropriate.
C. Prohibiting herbal tea without considering the client’s preferences or potential benefits is not patient-centered care.
D. Questioning the client's choice without a valid reason dismisses their preferences and does not address potential safety concerns.