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 D

Explanation

Falsely imprisoning a client involves restricting their freedom and movement against their will without proper legal authority or justification. Option D demonstrates false imprisonment because the nurse applies restraints to restrict the client's movement and then forces the medication into the client's mouth, essentially depriving the client of their right to refuse treatment.

Options A, B, and C are not examples of false imprisonment:

A. The nurse informing the client that the behavior will not be tolerated and will be addressed by the psychiatrist is a response to the client's inappropriate behavior. It does not involve restricting the client's freedom or movement.

B. The nurse throwing the medication in the trash and documenting the client's refusal is an appropriate response to the client's refusal of medication. It respects the client's right to refuse treatment.

C. The nurse pushing the client and causing them to fall to the floor, resulting in a nosebleed, is an example of physical assault and battery, not false imprisonment. It is an inappropriate and harmful action by the nurse.

A. Anger B. Acceptance C. Bargaining D. Depression

Correct Answer is C

Explanation

The client's statement, "I really want to see my first grandchild born before I die. Is that too much to ask?" indicates that the client is experiencing the stage of bargaining in the grieving process. During this stage, individuals may try to negotiate or make deals with a higher power or with fate in an attempt to postpone or change the outcome of their situation. In this case, the client is expressing a desire to live long enough to witness the birth of their first grandchild, which represents an attempt to negotiate with their illness and impending death.

It's important for the nurse to be supportive and empathetic during this stage of grieving and to provide emotional support to the client as they navigate their feelings and thoughts about their illness and impending death. Explanation: The client's statement, "I really want to see my first grandchild born before I die. Is that too much to ask?" indicates that the client is experiencing the stage of grieving known as bargaining.

In the context of the five stages of grief proposed by Elisabeth Kübler-Ross, bargaining is the third stage. During this stage, individuals may attempt to negotiate or make deals with a higher power or the universe to change the outcome of their situation. They may express thoughts like "If only I could see this happen before I die," as a way to find some sense of control or hope amidst their terminal illness.

In this scenario, the client's desire to see their first grandchild born reflects the bargaining stage, where they are trying to find meaning and hope in their terminal condition by wishing for a specific event to occur before their passing.

The other stages of grief include:

A. Anger - In this stage, individuals may feel resentful, frustrated, or outraged about their situation or the circumstances leading to their illness.

B. Acceptance - The final stage in Kübler-Ross's model, acceptance, involves coming to terms with one's imminent death and finding peace and resolution.

D. Depression - In this stage, individuals may experience profound sadness and a sense of loss related to their impending death and the life they will leave behind.

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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 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?

Correct Answer is D

Explanation

The client with terminal lung cancer says to the nurse. "I really want to see my first grandchild born before I die. Is that too much to ask?" Which stage of grieving will the nurse document the client is experiencing?

Correct Answer is C

Explanation

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?

A young client tells the nurse that the client's spouse died 3 months ago, and the client is feeling alone and vulnerable. Which statement indicates that the client's coping skills are adequate?

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?

A client who has been physically aggressive arrives at the emergency department for a psychiatric assessment. Which approach would be best for the nurse to use?

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?

The nurse is caring for several clients on the behavioral health unit. Which client will be assessed as demonstrating aggression?

The nurse approaches a client who looks very sad and is sitting alone crying. Which is the best response by the nurse in this situation?

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