Examkin

Soru

Zorluk: OrtaAbuse and Neglect

An emergency department nurse is caring for an 8-year-old client who presents with a spiral fracture of the left humerus. The parent states the child fell off a bicycle. During the physical examination, the nurse observes fading, varied-colored bruises on the child's torso. The child is unusually withdrawn and constantly looks at the parent before answering any questions. Which of the following is the priority nursing action?

  1. Separate the child from the parent to conduct a private interview and physical assessment.Cevap
  2. B
    Inform the parent that the observed physical injuries are inconsistent with a bicycle fall.
  3. C
    Wait for the healthcare provider to officially confirm non-accidental trauma before reporting the incident.
  4. D
    Instruct the unlicensed assistive personnel (UAP) to sit with the child and ask how the torso bruises occurred.

Cevap

Separate the child from the parent to conduct a private interview and physical assessment.
When child abuse is suspected, the immediate priority is to ensure the child's safety. Separating the child from the suspected abuser allows the nurse to conduct a thorough, objective assessment and interview the child in a safe, private environment without intimidation or influence from the parent.

Adım Adım Çözüm

1
Analyze the clinical cues presented in the scenario.
The child has a spiral fracture (often caused by twisting), bruises in varying stages of healing (indicating multiple incidents over time), and demonstrates fearful, guarded behavior.
These findings are strong indicators of potential child abuse and require immediate intervention.
2
Identify the primary nursing goal in suspected abuse cases.
The most immediate goal is ensuring the physical and emotional safety of the vulnerable client.
Protecting the client from further harm and preventing the suspected abuser from fleeing with the client is critical.
3
Evaluate the proposed interventions against safety and legal standards.
Confronting the parent increases risk. Delaying the report violates mandated reporting laws. Delegating the assessment is outside the UAP scope of practice. Separating the child provides a safe environment.
Only separation allows for a safe, uninfluenced assessment by the registered nurse.

Anahtar Kavram

Prioritizing client safety and independent assessment in suspected child abuse cases.
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Konular

Abuse and Neglect

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