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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Free Nursing Study Resources

Correct Answer is ["0.6"]

Explanation

Step 1: Determine the dosage available per mL.

Available dosage is 8 mg in 0.4 mL.
Calculation: 8 mg ÷ 0.4 mL = 20 mg/mL.
Result: 20 mg/mL.

Step 2: Calculate the volume needed for 12 mg.

Required dosage is 12 mg.
Calculation: 12 mg ÷ 20 mg/mL = 0.6 mL.
Result: 0.6 mL.

So, the nurse should administer 0.6 mL of methylnaltrexone.

A. Ask the client if they are in denial regarding the seriousness of their illness. B. Be an active listener and use silence to facilitate communication. C. Refer the client to the chaplain for religious counseling. D. Inform the client that since it is too late to change, acceptance is inevitable.

Correct Answer is B

Explanation

Using active listening techniques and providing a supportive and non-judgmental environment can promote the client's ability to express their feelings. Many clients facing end-stage illnesses, such as alcoholic cirrhosis, may experience a range of emotions and find it difficult to talk about their illness or impending loss of life. By being present, attentive, and using silence when appropriate, the nurse allows the client the space and time they need to process their thoughts and emotions and feel comfortable expressing their feelings when they are ready.

Incorrect:

Option A may come across as confrontational and judgmental, which can hinder the client's willingness to share their feelings.

Option C may be appropriate if the client requests spiritual or religious support, but it should not be assumed as the primary intervention for promoting emotional expression.

Option D can be seen as dismissive and insensitive to the client's emotional needs, and it may not be helpful in encouraging the client to open up about their feelings.

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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

Correct Answer is ["0.6"]

Explanation

A client with end-stage alcoholic cirrhosis of the liver is hesitant to talk about the illness and the impending loss of life from their alcohol use disorder. Which action by the nurse can promote the client's ability to express their feelings?

Correct Answer is B

Explanation

The nurse is completing a family assessment for a victim of intimate partner violence. Which characteristic of the abuser will the nurse identify when completing the assessment?

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

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 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.)

A nurse is questioning another nurse about whether it is ethical to seclude a client because of loud and intrusive behavior on the unit. Which is the ethical principle that will best guide the nurse's decision on the appropriate use of seclusion?