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

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.

A. "You may be in more physical danger after you leave them." B. "Batterers never change, so it would be best for you to leave." C. "If you leave, maybe your partner will see that they have to change their behavior." D. "If you don't leave. your partner will think you're going to continue to endure the abuse."

Correct Answer is A

Explanation

This is the best response because it acknowledges the client’s statement while providing realistic, evidence-based information. According to the National Institute of Mental Health (NIMH) and domestic violence research, the period immediately after leaving an abusive partner is often the most dangerous, as abusers may escalate threats or violence when they feel a loss of control. This response validates the client’s concerns, offers safety awareness, and opens the door for further discussion about creating a safety plan.

option B generalizes that all batterers never change, which may not be true for all situations and individuals.

Option C suggeststhat leaving will make the partner change is inappropriate and unsafe. This could give the client false hope that the abuser’s behavior will improve, when evidence shows that abusive partners rarely change without intensive intervention.

Option D may imply a threat or ultimatum, which is not appropriate and can be disempowering for the client. The most important aspect of supporting someone in an abusive relationship is to provide a non-judgmental, understanding, and empowering environment where they can explore their options and make decisions that are best for their safety and well-being.

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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

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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