Today’s NCLEX-RN® question of the day focuses on a nurse examining a 9-year-old child with leg pain.
A 9-year-old child is sent to the school nurse’s office because of a painful leg. When examining the child, the nurse notes a belt buckle-shaped bruise. Which action should the nurse prioritize?
A. Talk to the child’s teacher about playground violence
B. Take a picture of the bruise for the child’s file
C. Assess the child for pain
D. Ask the child about the bruise
Scroll down for the correct answer!
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The correct answer to today’s NCLEX-RN® Question is…
D. Ask the child about the bruise
Rationale: Asking the child about the bruise will give the nurse additional assessment data and will provide an opportunity for the child to ask for help. This is the action that should be prioritized.
Main takeaway
Because nurses and other healthcare professionals are mandated reporters, the nurse should ask the child about the bruise and also report the findings to the appropriate child protective agency. Continuing to assess for pain, checking for other injuries, documenting the bruise, and talking to the child’s teacher are not the priority nursing interventions.
Incorrect answer explanations
A. Talk to the child’s teacher about playground violence
Rationale: Talking to the child’s teacher is not the priority action since a buckle-shaped bruise on the leg is more likely to have happened at home.
B. Take a picture of the bruise for the child’s file
Rationale: The bruise should be documented, but this is not the priority action.
C. Assess the child for pain
Rationale: In addition to assessment for other injuries, pain assessment is an appropriate action; however, this is not the priority action.
References
Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2017). Fundamentals of nursing (9th ed.). St. Louis, MO: Elsevier/Mosby.
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