A pediatric nurse is caring for an 18-month-old client. While ...

[CBme]

A pediatric nurse is caring for an 18-month-old client. While making rounds the nurse enters the room and finds the infant's father violently shaking the infant.
 
  The father attempts to make it appear as though the infant was choking. Upon further assessment the nurse notes bruised areas on the infant's arms and legs. What is a priority action for the nurse to take?
  A) Discuss what she witnessed with the infant's mother.
  B) Discuss what she witnessed with the other nurses.
  C) Report what she witnessed and assessed to child protective services.
  D) Report what she witnessed and assessed to the local law enforcement agency.

Question 2

The nurse is completing a morning assessment on an older adult Asian client. Assessment findings reveal circular red welts over the client's upper back with several bruised areas. Which nursing action is the most appropriate?
 
  A) Contact adult protective services.
  B) Call the healthcare provider immediately.
  C) Assess the client's spiritual beliefs.
  D) Contact the client's family.

[missalyssa26]

Answer to Question 1

Answer: C

Due to mandatory reporting laws, nurses must report all suspected cases of child abuse to the appropriate child protective services agency. It would not be appropriate at this time to discuss the findings with the infant's mother. The nurse does not know if the mother is aware of what is occurring and it would be best to have this further investigated. It would not be appropriate to discuss the findings with the other nurses as due to privacy regulations this information would be shared on a need-to-know basis.

Answer to Question 2

Answer: C

The most appropriate action for the nurse at this time is to assess the client's spiritual beliefs. The practice of cupping is generally practiced by many Asian cultures, as well as individuals who participate in holistic healing. Cupping is the act of placing a glass cup on the skin, and then using heat to create suction; often this is performed to promote blood flow and overall healing. The result of the procedure can be circular red welts or even dark bruising, which are often found along the individual's back. This treatment is not abusive in nature, but rather a form of healing.

[CBme]

Thank you

[missalyssa26]

No problemo