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Difficulty: MediumAbuse and Neglect

A 16-year-old client is evaluated in the emergency department for a facial laceration and bilateral fading bruises on the upper arms. The client's parent stands closely over the stretcher, repeatedly answers questions on the client's behalf, and states loudly, "If you weren't so clumsy all the time, we wouldn't be here." The client is trembling and avoids eye contact. Which of the following is the priority nursing action?

  1. Explain that hospital policy requires a private intake assessment for all adolescents and escort the client to a separate room.Answer
  2. B
    Directly confront the parent about their intimidating behavior and instruct them to remain in the waiting area.
  3. C
    Document the interactions and wait for the attending healthcare provider to determine if a child protective services report is warranted.
  4. D
    Instruct the unlicensed assistive personnel (UAP) to sit with the client while the nurse interviews the parent privately in the hallway.

Answer

The priority action is to separate the client from the parent by explaining that hospital policy requires a private intake assessment for all adolescents, and then escorting the client to a separate room.
When abuse is suspected, the immediate nursing priority is to ensure the client's physical safety and provide a secure environment for a private assessment. Using a standard hospital policy as the rationale for separating the client from the parent prevents escalating the suspected abuser's agitation while successfully removing the client from potential immediate harm. Once separated, the nurse can safely assess the client, gather necessary information, and initiate mandatory reporting procedures.

Step-by-Step Solution

1
Analyze the clinical scenario and client presentation.
The client presents with unexplained injuries and displays fearful behavior (trembling, avoiding eye contact), while the parent is overbearing, aggressive, and answering on behalf of the client.
These are classical red flags indicating physical abuse and intimidation.
2
Identify the immediate nursing priority.
The most urgent need is to ensure client safety and conduct a thorough, private assessment away from the suspected abuser.
The client cannot safely disclose abuse or be properly assessed while the intimidating parent is present.
3
Select the safest method to achieve the priority.
Using a routine unit policy as the reason to separate the client and parent.
This strategy de-escalates the situation and avoids provoking the parent, ensuring the immediate physical safety of the client without causing a confrontation.

Key Concept

Immediate safety and separation from the suspected abuser in cases of suspected child or adolescent abuse.
Estimated Time:1m 0s
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Topics

Abuse and Neglect

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