A woman with multiple bruises on her face and arms is seen in the emergency department. Her significant other is with her. When asked about her injuries, the woman states, "I ran into a door."
Which action by the nurse is of highest priority? 1. Take the woman's vital signs.
2. Document the location of the bruises.
3. Assess for additional bruising.
4. Interview the woman in private.
4
Rationale 1: Taking the woman's vital signs is important, but not the highest priority.
Rationale 2: Documenting the location of the bruises is important, but not the highest priority.
Rationale 3: Assessing for additional bruising is something that will have to be done, but is not the first priority.
Rationale 4: Interviewing the patient in private is the first priority, as the nurse needs to get the patient away from her partner and ask her some questions.
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