71. Which documentation would be appropriate by a nurse who suspects child abuse or neglect? Select all that apply.
71. Which documentation would be appropriate by a nurse who suspects child abuse or neglect? Select all that apply.
. Child states, "My little brother hit me."
. Mother appears stressed by hospital environment.
. Parents do not take interest in caring for child.
. Child's height-weight ratio is below 5th percentile.
. Parent reports that the child has not seen a physician for 1 year.
. When asked by physician about bruising, child refused to answer.
Test-Taking Tip
When charting, the nurse should always strive for objective language by stating facts in measurable and precise phrases. Subjective language introduces the nurse's bias and must be avoided.
Content Area: Child Health, Abuse; Integrated Process: Communication and Documentation; Cognitive Level: Application; Client Need/Subneed: Psychosocial Integrity/Abuse/Neglect
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Answer 1 is correct because the nurse charts the child's words exactly as they were spoken, using quotes. Answer 2 is incorrect because the nurse is charting a personal interpretation of the mother's reaction to the environment. Additionally, many parents are stressed in the hospital environment, making this charting entry of questionable value. Answer 3 is incorrect because this is a vague description and is a subjective interpretation. A better entry would be to describe a specific event such as the parent failing to visit during the child's hospitalization. Answer 4 is correct because this is an objective piece of data that is easily measured. Answer 5 is correct because the nurse reports a period of time as stated by the parents. Answer 6 is correct because this succinctly describes the interaction between physician and child.