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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
When a nurse observes another nurse acting flirtatiously and bringing small gifts to a client in the behavioral health unit, it raises concerns about professional boundaries and the potential for unethical behavior. The priority action for the observing nurse is to protect the rights and well-being of the client.
Option A, reporting the behavior to the supervisor, is the appropriate course of action. Reporting the observed behavior to the supervisor ensures that the situation is investigated and addressed by the appropriate authorities within the healthcare facility. This action helps maintain the integrity of the therapeutic relationship between the client and healthcare team and protects the client from any potential exploitation or manipulation.
Options B, C and D are not appropriate actions:
B. Ignoring the behavior is not appropriate as it does not address the concerns about professional boundaries and the potential for unethical behavior. Ignoring such behavior may allow it to continue, potentially putting the client at risk.
C. Confronting the nurse directly without first reporting the behavior to the supervisor may not be the most appropriate course of action. It is essential to involve the appropriate authorities within the healthcare facility to conduct a proper investigation and address the situation professionally.
D. Discussing the situation with the client and making assumptions about emotional manipulation may not be appropriate or accurate. It is not the observing nurse's role to discuss such matters with the client. Instead, the appropriate course of action is to report the observed behavior to the supervisor or appropriate authority within the healthcare facility.
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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