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 C
Explanation
Rationale:
A. Discussing fears with anyone is not the most immediate question to ask when assessing for safety; it may be relevant later but does not directly address immediate safety concerns.
B. Fears about the spouse could be a part of the assessment but are more specific than asking about overall safety.
C. Asking if the client feels safe in the home is a direct and straightforward question that addresses immediate safety concerns and can provide crucial information about the presence of abuse.
D. Recommending a safe place may be helpful but should come after establishing the client’s current safety and assessing immediate risks.
Correct Answer is C
Explanation
Rationale:
A. Discouraging the client from using any alternative therapies is not appropriate as it disregards the client’s autonomy and preferences. It is important to respect the client’s choices while providing evidence-based guidance.
B. Advising the client about "good" versus "bad" therapies can be subjective and may not provide the comprehensive information the client needs. Instead, focus should be on evidence-based information.
C. Educating the client about therapies that they are using or interested in ensures they are informed about potential benefits, risks, and interactions with conventional treatments. This approach supports informed decision-making and safe use of complementary and alternative therapies.
D. Recommending herbal remedies is outside the scope of the nurse's role unless there is clear evidence-based information to support such recommendations. Nurses should focus on providing education rather than specific recommendations.