# 護理師注意到一名幼兒身上有多處不同癒合階段的瘀傷。照顧者提供的解釋與傷勢不符。護理師應採取哪項行動？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397450&lang=zh-tw  
> language: zh-TW  
> subject: Informed Consent  
> category: MOC

## 題目

護理師注意到一名幼兒身上有多處不同癒合階段的瘀傷。照顧者提供的解釋與傷勢不符。護理師應採取哪項行動？

## 選項

1. 遵循機構政策通報疑似兒童虐待。 **✔ 正確答案**
2. 要求照顧者簽署一份承認虐待的聲明。
3. 等到護理師確定發生了什麼事再處理。
4. 告訴照顧者，除非說法改變，否則孩子不能出院。

**正確答案: 1**

## 解析

護理師是法定通報人，應根據法律和機構政策通報疑似虐待。在有合理懷疑時，不需要確定性或照顧者承認即可通報。威脅照顧者或試圖取得供詞可能會危及安全和調查。

## 深入解析

臨床判斷
使用個案線索、時間點、檢驗數據和安全風險，選擇最符合疑似兒童虐待通報的回應。

記憶提示
將最強的線索群與最安全的護理判斷配對。

KR vs US
NCLEX 考題獎勵基於線索的優先思考，而非孤立的回憶。

## 臨床情境

臨床實務指引
對於疑似兒童虐待通報，將完整的線索模式與個案當前的穩定性、醫囑數據和預期的護理範圍進行比較。

注意
當完整情境改變了優先順序或安全性時，不要僅根據一個孤立的線索選擇行動。

## 重要概念

- **法定通報人** — 法律上要求通報疑似虐待或疏忽的專業人員。
- **客觀記錄** — 記錄可觀察到的發現，而不包含未經證實的結論。
- **合理懷疑** — 基於線索的擔憂，足以觸發必要的通報。

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