The school nurse is seeing a 7-year-old child in the clinic and is concerned with behaviors and physical indications that indicate the child is being sexually abused. Which is the priority action by the nurse?

The nurse must discuss the findings with the parents and give them the opportunity to explain.

Talk to the child and find out if they are experiencing sexual abuse or inappropriate touching.

The nurse should talk with another co-worker to be sure the nurse is correct about the assessment.

Accurately and thoroughly document the findings and report to the appropriate authorities.

Answer and Explanation

The Correct Answer is D

When a school nurse suspects that a child is being sexually abused, the priority action is to ensure the child's safety and well-being. Option D, accurately and thoroughly documenting the findings and reporting to the appropriate authorities, is the most critical step in protecting the child.

Child abuse, including sexual abuse, is a serious concern that requires immediate attention and intervention. In many jurisdictions, healthcare professionals, including school nurses, are mandated reporters, which means they are legally obligated to report suspected cases of child abuse to child protective services or other appropriate authorities.

Options A, B, and C are not appropriate as the child's safety is the top priority:

A. Discussing the findings with the parents and giving them the opportunity to explain could potentially place the child at further risk if the parents are involved in the abuse or are unwilling to address the situation.

B. Talking to the child and finding out if they are experiencing sexual abuse or inappropriate touching should not be the first step without involving child protective services or other appropriate authorities. The child may be frightened or reluctant to disclose abuse directly to the nurse, especially if the abuser is a family member or someone known to the child.

C. Talking with another co-worker to confirm the assessment may delay the necessary action and reporting to protect the child.

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Correct Answer is C

Explanation

The client's observed behavior of pacing the hall with clenched fists and swearing at others indicates that they are in the escalation phase of the aggression cycle. During this phase, the individual's anger and agitation increase, and their behavior becomes more intense and aggressive. If not addressed promptly and effectively, the situation can escalate further and potentially lead to a crisis or violent outburst.

By intervening immediately and calmly, the nurse aims to prevent the situation from escalating further and moving into the crisis phase, where the risk of harm to the client and others is highest. Effective de-escalation techniques, such as using a calm and non-threatening demeanor, active listening, and providing clear and respectful communication, can help the client regain control and reduce their agitation.

Option A - Recovery: The recovery phase comes after the aggressive incident, during which the individual may feel remorse or embarrassment about their behavior.

Option B - Crisis: The crisis phase is the point where the individual's anger and agitation reach a peak, and there is a high risk of violence or harmful actions.

Option D - Triggering: The triggering phase is the initial phase of the aggression cycle, where the individual's anger begins to build, and certain triggers may set off their aggressive behavior.

A. "Do you have enough money to pay for your care today? B. "Do you feel safe in your home?" C. "Do you take Illegal street drugs? D. Do you obtain regular medical care?

Correct Answer is B

Explanation

Explanation: The priority question the nurse should ask the client during the initial assessment is whether they feel safe in their home (Option B). This question is essential because it addresses the client's safety and well-being, particularly regarding the possibility of domestic violence or intimate partner violence.

Assessing for safety is a critical component of the initial assessment, especially for female clients, as they may be at higher risk for experiencing domestic violence or abuse. By asking about the client's safety in their home, the nurse can identify potential issues related to violence or unsafe living conditions and take appropriate actions to ensure the client's safety.

Options A, C, and D are also important assessment questions, but they are not the priority in this scenario:

A. "Do you have enough money to pay for your care today?" - This is an important question regarding the client's financial situation and ability to access healthcare. However, safety and well-being take precedence over financial concerns in the initial assessment.

C. "Do you take illegal street drugs?" - This question is crucial for assessing the client's substance use and potential risk factors related to drug use. However, the safety question (Option B) is more immediate and directly addresses the client's well-being.

D. "Do you obtain regular medical care?" - This question is vital for assessing the client's healthcare needs and access to healthcare services. However, the safety question (Option B) should be addressed first to ensure the client's immediate safety and well-being.

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The school nurse is seeing a 7-year-old child in the clinic and is concerned with behaviors and physical indications that indicate the child is being sexually abused. Which is the priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is observed pacing the hall with clenched fists and swearing at others. The nurse intervenes immediately in a calm manner to prevent the client from moving to which phase of the aggression cycle?

Correct Answer is C

Explanation

The nurse working in an outpatient clinic is performing an intake assessment for a female client. Which priority question will the nurse ask the client as part of the initial assessment?

Correct Answer is B

Explanation

The health care provider prescribes haloperidol 10 mg for a client with severe psychosis but the client refuses the medication. Which nursing action is appropriate?

A client is informed by the nurse that they must take their medication, and the client kicks the nurse and runs to their room. Which action by the nurse demonstrates that the nurse falsely imprisons the client?

After an Angry outburst, a client quickly appears calmer and receptive to input from the nurse. Which is the most helpful response to the client at this time?

A nurse cared for a terminally ill client for over a month and developed a therapeutic nurse-client relationship. After the client's death, feelings of sadness. sleeping poorly, and feeling mildly depressed were experienced by the nurse. Which is the best action to improve the resolution of grief?

The nurse is caring for a client who has been a victim of abuse since childhood. Which action(s) by the nurse is important so that the client feels safe, secure, and in control of their own body? Select all that apply. (Select All that Apply.)

The nurse is working with another nurse in the emergency department (ED) when a client comes in stating they have been raped during a date. Which statement made by the other nurse privately requires immediate correction?

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A nurse auscultates a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take