A patient diagnosed with schizophrenia may demonstrate these positive symptoms (select all that apply) :

Choice A reason : While it is true that a healthcare provider may come to explain the situation, this response does not directly address the parent's concern about the reason for the nurse's action. It is important for the nurse to communicate clearly and directly about their responsibilities and the actions they have taken.

Choice B reason : This response indicates that the nurse has taken action by reporting to a supervisor, but it does not clarify the nurse's legal obligation to report suspected child abuse. It is essential for nurses to understand and communicate their role as mandated reporters to ensure transparency and trust in the healthcare setting¹.

Choice C reason : This is the most appropriate response because it directly addresses the parent's question and explains the nurse's legal responsibility. Nurses are mandated reporters and are legally required to report any suspicions of child abuse to protect the child's welfare. This response is clear, direct, and upholds the nurse's professional and legal obligations¹³.

Choice D reason : While contacting a supervisor may be part of the protocol, this response does not provide the parent with an explanation for the nurse's action. It is important for the nurse to explain their legal duty to report suspected child abuse, which is the primary reason for their action.

Choice A reason : The plantar reflex, also known as the Babinski sign, is elicited by stroking the lateral aspect of the sole of the foot. A positive response is indicated by dorsiflexion of the big toe and fanning of the other toes. This reflex is normal in infants but may indicate central nervous system damage in adults¹. However, it is not specifically associated with meningeal irritation.

Choice B reason : Kernig's sign is a clinical sign wherein the patient experiences severe stiffness of the hamstrings causing an inability to straighten the leg when the hip is flexed to 90 degrees. This sign can indicate meningeal irritation but is not as early a sign as Brudzinski's sign².

Choice C reason : Brudzinski's sign is one of the most indicative signs of meningeal irritation. When the neck is flexed, there is involuntary flexion of the hips and knees. This reflex is an early sign of meningeal irritation and is considered a critical manifestation in assessing meningitis following head trauma².

Choice D reason : Sunsetting eyes, characterized by the downward deviation of the eyes, is associated with increased intracranial pressure, which can occur in conditions like hydrocephalus. While it may be seen in the context of brain injury, it is not a specific sign of meningeal irritation³.