# A nurse is caring for a 4-year-old child who has been admitted with suspicious injuries consistent with physical abuse. The child is withdrawn, fearful, and has not spoken since admission. Which nursing intervention should be the priority?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=319659  
> language: ko  
> subject: Mental Health

## 문제

A nurse is caring for a 4-year-old child who has been admitted with suspicious injuries consistent with physical abuse. The child is withdrawn, fearful, and has not spoken since admission. Which nursing intervention should be the priority?

## 보기

1. Establish a trusting relationship through consistent, gentle interactions and respect for the child's boundaries. **✔ 정답**
2. Encourage the child to discuss the details of how the injuries occurred to gather evidence for legal proceedings.
3. Take detailed photographs of all injuries for documentation purposes
4. Restrict all family visits until the investigation is complete

**정답: 1**

## 해설

Establishing trust through gentle, non-threatening interactions is the priority to ensure the child's emotional safety and facilitate future communication. Other interventions like detailed documentation or restricting family visits are important but secondary to building rapport.

## 심화 해설

Core Nursing Explanation
**Key Concept Analysis**: This question assesses the priority nursing intervention for a suspected victim of child abuse, specifically focusing on the nursing process and the principle of patient safety. The core theme is the Key Point! **hierarchical nature of patient needs**. According to Maslow's hierarchy and nursing priorities, psychological safety and trust are foundational before any investigative or procedural steps can be effective. The child's withdrawn, fearful, and nonverbal state indicates significant emotional trauma and a lack of a safe environment.

**Answer Rationale**: The correct answer is to Establish a trusting relationship through consistent, gentle interactions and respect for the child's boundaries. This is the priority because:
1. **Emotional Safety First**: The child's immediate need is to feel safe. Without a sense of safety and trust, the child will not communicate, cooperate with care, or begin to heal. The nurse's primary role is to be a non-threatening, protective figure.
2. **Foundation for All Other Care**: Effective assessment, documentation, and legal procedures depend on the child's ability to engage. Building rapport is the essential first step that enables all subsequent interventions.
3. **Respects Autonomy and Trauma**: Respecting the child's boundaries (e.g., not forcing conversation or touch) is a trauma-informed approach that empowers the child and helps rebuild a sense of control.

**Distractor Analysis**:
Watch out for confusion! While the other actions are necessary parts of caring for a suspected abuse victim, they are not the *immediate priority* for this specific child at this moment.

- Option ② (Encourage the child to discuss the details...): This is incorrect and potentially harmful. Pressuring a traumatized, nonverbal child to recount events can re-traumatize them and is not the nurse's role for evidence gathering. Forensic interviews are conducted by trained specialists in a controlled setting.

- Option ③ (Take detailed photographs...): Documentation is a critical **secondary** intervention. However, attempting this before establishing trust could be perceived as a violation, frightening the child, and compromising the nurse-patient relationship. It should be done systematically and sensitively, often with the help of a child life specialist or forensic nurse.

- Option ④ (Restrict all family visits...): This is an extreme measure that requires a specific safety assessment and is usually a decision made by the healthcare team, child protective services, and possibly law enforcement. Automatically restricting all visits without assessment may not be in the child's best interest if there are non-abusive family members who provide comfort. The priority is to assess the situation and create a safe plan, not to isolate the child first.

**Related Concepts**: This scenario integrates mandatory reporting laws, trauma-informed care, the role of the nurse as a patient advocate, and the legal/ethical responsibilities in suspected abuse cases. The nursing process guides us: **Assessment** (observing behavior, injuries), **Diagnosis** (e.g., Fear, Risk for Injury), **Planning** (creating a safe environment), **Implementation** (building trust), and **Evaluation** (monitoring the child's response).

## 임상 시나리오

Nursing Clinical Practice Guide
**Clinical Scenario**: You are the nurse on a pediatric unit. A 4-year-old, "Liam," is admitted with multiple bruises in various stages of healing and a suspicious spiral fracture of the femur. He clings to a stuffed animal, avoids eye contact, and flinches when you approach. His parents provide a conflicting history of the injury.

**Nursing Intervention Strategy**:
1.  **Immediate Action (Priority)**: Introduce yourself calmly. Sit at the child's eye level, not directly in front of him. Use a soft voice. Say, "Hi Liam, my name is [Name]. I'm a nurse here to help you feel safe. This is your room. You can keep your toy with you." Focus on non-verbal communication—offer a coloring book without demanding interaction.
2.  **Environment**: Assign consistent nurses to provide predictability. Ensure the room is quiet and his bed is in a location where he can see the door (so he doesn't feel trapped).
3.  **Assessment & Documentation**: Once rapport begins, perform a head-to-toe assessment gently, explaining each step. Use a body map diagram to document the size, shape, color, and location of every mark. *Photographs* should be taken per hospital protocol, ideally by a designated person (e.g., SANE nurse) with proper consent/authorization.
4.  **Family & Legal**: Follow your institution's protocol for suspected abuse, which will include notifying the physician, social work, and filing a mandatory report to Child Protective Services (CPS). Assess family dynamics; do not make accusatory statements. Visitation may be supervised based on the safety plan developed with CPS.

**Patient Safety and Precautions**:
- **Confidentiality**: Document objectively without speculation (e.g., "client states he fell off the couch" vs. "injury inconsistent with reported mechanism").
- **Non-leading Questions**: Never ask "Did your dad hit you?" Instead, use open-ended statements: "Sometimes kids get hurt. Can you tell me what happened?"
- **Self-Care**: Cases of child abuse are emotionally taxing for nurses. Utilize debriefing sessions and peer support.

Nursing Procedure & Medication Flow
While not a medication procedure, the procedural flow for this case is critical:
1.  **Secure Physical Safety**: Ensure immediate medical needs (fracture care) are met.
2.  **Establish Psychological Safety (PRIORITY)**: Build trust as outlined.
3.  **Systematic Assessment**: Complete thorough physical and psychosocial assessments.
4.  **Objective Documentation**: Chart findings factually. "Bruise, 3cm x 2cm, blue-green-yellow, posterior right thigh."
5.  **Activate Multidisciplinary Team**: Notify physician, social work, charge nurse, and security per protocol.
6.  **Legal Duty**: File the mandatory report. Know your state's specific requirements and timelines.

A Word from Your Senior Nurse
"In cases like this, your presence is your most powerful tool. That scared, silent child is looking for one safe harbor. By prioritizing trust over tasks, you're not just being kind—you're practicing clinically sound, trauma-informed nursing. You are laying the groundwork for healing and for any successful legal intervention. Remember, on the NCLEX and at the bedside, the answer that focuses on the patient's immediate emotional and physical safety is almost always the priority. You are the advocate they need right now."

## 핵심 개념

- **Child Abuse** — Any act or failure to act by a parent, caregiver, or other person that results in actual or potential harm to a child. Includes physical, sexual, emotional abuse, and neglect.
- **Trauma-Informed Care** — An organizational structure and treatment framework that involves understanding, recognizing, and responding to the effects of all types of trauma, emphasizing physical, psychological, and emotional safety.
- **Mandatory Reporting** — A legal requirement for certain professionals, including nurses, to report suspected cases of child abuse or neglect to the designated state authority (e.g., Child Protective Services).
- **Nursing Process** — A systematic, cyclical framework for providing nursing care: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE).
- **Patient Advocate** — The role of the nurse in protecting the patient's rights, promoting their best interests, and ensuring they receive proper care and information, especially for vulnerable populations.

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