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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Option C demonstrates empathy and active listening. By acknowledging the client's emotions and expressing concern, the nurse creates a safe and supportive environment for the client to share their feelings. This response encourages the client to open up and express what they are going through, allowing the nurse to better understand the situation and provide appropriate care and support.

Options A and D are also empathetic but may not prompt the client to share their feelings or concerns as effectively as Option C.

Option B is not appropriate as it minimizes the client's emotions and may discourage them from expressing their feelings further.

A. "We will have to talk about this later." B. "what happened that got you so upset?" C. "You really scared me. I'm glad you are okay." D. "Your behavior is unacceptable and will not be tolerated

Correct Answer is B

Explanation

When a client has an angry outburst and then quickly appears calmer and receptive to input from the nurse, it is important for the nurse to address the underlying cause of the outburst and explore the client's feelings and emotions. By asking, "What happened that got you so upset?", the nurse is inviting the client to express their feelings and share what triggered their anger. This can help the nurse understand the client's perspective, provide appropriate support, and potentially de-escalate any remaining tension or frustration.

The other options are inappropriate because:

A- "We will have to talk about this later." This response may make the client feel dismissed or that their feelings are not being heard or understood.

C- "You really scared me. I'm glad you are okay." While this response acknowledges the client's emotional state, it centers the focus on the nurse's feelings rather than exploring the client's perspective or emotions.

D- "Your behavior is unacceptable and will not be tolerated." This response is confrontational and judgmental, which can escalate the situation and potentially trigger further defensive reactions from the client.

Overall, a non-judgmental and empathetic approach that focuses on understanding the client's feelings and experiences is more likely to foster open communication and provide the client with a safe space to express themselves.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

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?

Correct Answer is C

Explanation

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?

Correct Answer is B

Explanation

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?

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?

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.)

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?

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 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?

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?