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. Providing a personal emergency response system is important but does not address the immediate physical hazards in the home that are likely to cause falls.
B. Installing grab bars and handrails is a good safety measure, but addressing immediate tripping hazards should take precedence to prevent falls.
C. Removing clutter and securing loose rugs is a direct intervention that addresses the immediate risk factors for falls in the home environment. This should be the first step in improving safety.
D. Modifying the exercise routine can be beneficial for long-term fall prevention but does not address the immediate physical hazards present in the home.
Correct Answer is A
Explanation
Rationale:
A. Stockholm Syndrome is a psychological phenomenon where victims develop positive feelings toward their captors or abusers and negative feelings toward those who oppose them.
B. Extreme stress may occur in victims but does not specifically describe the loyalty and negative feelings toward others as described.
C. Glamorizing exploitation refers to viewing exploitation in a positive light, which does not align with the feelings of loyalty and animosity described.
D. Sexual confusion does not accurately capture the dynamics of loyalty to a controller and hostility toward others.