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 ["B","C","D"]

Explanation

Complicated grieving, also known as complicated grief or prolonged grief disorder, refers to a type of grief that is prolonged, intense and does not follow the typical trajectory of mourning. It can manifest differently in different individuals, but some common signs of complicated grieving include:

B. An adult who insisted for many years that the adult hated the adult's deceased parent: This could indicate unresolved emotional conflicts with the deceased parent, which may be contributing to complicated grief.

C. The parent of a child who died after having left the child in a car on a hot day: This situation involves feelings of guilt and responsibility, which can complicate the grieving process.

D. The grandchild of a soldier killed in war who visits the grave once a year on Memorial Day: This response is likely a normal grief response, as the person visits the grave once a year during Memorial Day, which is a common time for remembering and honoring deceased loved ones.

The following options are not necessarily indicative of complicated grieving:

A. A driver whose spouse and children all died as a result of his driving drunk: While this is undoubtedly a traumatic event, the description provided does not necessarily indicate complicated grieving specifically.

E. The spouse of a person who died 7 years ago and visits the grave several times a day: Visiting the grave several times a day might indicate a deep sense of loss, but it is not specific to complicated grieving and can vary depending on cultural practices and individual coping mechanisms.

It's essential to recognize that grief is a complex and individual process, and professional assessment and support are often required to identify and address complicated grieving in a person.

A. Laws do not provide protection against abuse when the suspect(s) is/are family members. B. The client has no financial resources to hire legal representation against the client's children. C. The client is emotionally close to the children and does not want to bring them harm. D. The client cannot claim abuse if there is no evidence of physical harm.

Correct Answer is C

Explanation

In cases of elder abuse by family members, the emotional bond and dependency on the abusers can create a significant barrier for the older adult to report the abuse. The client may fear damaging the relationship with their adult children or causing harm to the family dynamics. This emotional closeness and loyalty to the family may prevent the client from disclosing the abuse and seeking help.

Option A is not correct because laws do provide protection against elder abuse, including abuse by family members. Many jurisdictions have specific laws and protective services in place to address elder abuse.

Option B is not correct because financial resources, while important, are not the primary reason why the client has not reported the abuse. The emotional bond with the abusers is a more significant factor.

Option D is not correct because abuse does not need to involve physical harm to be considered abuse. Emotional, financial, and other forms of abuse can also be harmful and should be reported and addressed.

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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 nurse is assessing several clients who have experienced loss. Which client will the nurse identify as experiencing complicated grieving? Select all that apply. (Select All that Apply.)

Correct Answer is ["B","C","D"]

Explanation

An alert, oriented older adult client has been financially and emotionally abused by their adult children for the past several years but has not reported the abuse to anyone. Which reason does the nurse identify is most likely why the client has not reported the abuse?

Correct Answer is C

Explanation

The nurse is working with an adolescent client that is argumentative with staff and peers on the behavioral health unit. Which therapeutic response will be most beneficial for the client to decrease acting out behavior?

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 client with depression is found to have attempted suicide in the bathroom and sustained injury. There is no documentation that the client was assessed every hour as prescribed. Which issue will the nursing staff and hospital potentially have to defend against?

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 manipulative with staff and disruptive in the milieu. Although the client is not demonstrating behaviors that are a threat to self or others, they are refusing all medications. Which action by the nurse is most appropriate?

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