A 5-year-old girl is brought to the clinic for symptoms of a urinary tract infection (UTI). The nurse's assessment reveals bruises in the child's genital and rectal areas. The nurse's first priority with this client is:
Teach the mother about symptoms of UTI
Report suspected sexual abuse to protective services
Interview mother for child’s health history
Obtain a urine sample to confirm UTI
The Correct Answer is B
A. Teach the mother about symptoms of UTI is not the nurse's first priority. While educating the mother about UTIs is important, the presence of bruises in the genital and rectal areas raises immediate concern for potential sexual abuse, which requires immediate action to ensure the child's safety.
B. Report suspected sexual abuse to protective services is the nurse's first priority. Any signs of physical trauma or injury in areas typically covered by clothing, such as the genital and rectal areas, must be reported immediately. The nurse is a mandated reporter and is legally required to report any suspected abuse. Ensuring the safety of the child is paramount, and protective services will investigate the situation and take appropriate steps.
C. Interview mother for child’s health history may be necessary later, but at this moment, the immediate concern is the possibility of sexual abuse. The nurse should report the findings to the appropriate authorities before discussing the situation further with the mother.
D. Obtain a urine sample to confirm UTI is important for diagnosing the UTI but does not address the immediate concern regarding possible abuse. The child’s safety and well-being must be prioritized, and reporting the possible abuse is more urgent than confirming the UTI at this point.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Quetiapine (Seroquel) is an atypical antipsychotic medication used for the treatment of conditions like schizophrenia, bipolar disorder, and major depression. It is not commonly used for the immediate short-term treatment of someone who has been sexually assaulted.
B. Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI) used to treat depression, anxiety, and other mood disorders. While it may be used for long-term treatment of anxiety or depression, it is not typically the first-line choice for short-term treatment immediately after a sexual assault.
C. Cyclobenzaprine (Flexeril) is a muscle relaxant used for muscle spasms and is not typically used for short-term treatment following a sexual assault.
D. Lorazepam (Ativan) is a benzodiazepine used for its anxiolytic (anti-anxiety) and sedative properties. After a sexual assault, a victim may experience acute anxiety, panic, and distress. Lorazepam can be used short-term to help reduce anxiety, calm the individual, and assist in sleep. However, it should be used cautiously, considering the risk of dependency or sedation.
Correct Answer is A
Explanation
A. "If you are educated and have money, abuse does not happen" is a myth and a misconception about domestic violence. Abuse can occur in any relationship, regardless of socio-economic status, education, or wealth. Domestic violence can affect individuals of all backgrounds, including those who are educated or financially secure. This statement indicates a lack of understanding about the widespread nature of abuse, so further teaching is needed.
B. "Abusers are often excessively jealous and possessive" is a true statement. Many abusers exhibit controlling behavior, which can include jealousy and possessiveness. This is a common characteristic of abusive relationships.
C. "Violence often begins in a dating relationship" is also true. Domestic violence can begin in dating relationships, and early signs of abuse can include controlling behavior, verbal abuse, or physical aggression. Early education on this issue can help prevent future violence.
D. "The abuser will often apologize and promise to stop" is a true statement. Many abusers apologize after an incident and promise that it won’t happen again. This is part of the cycle of abuse, where the abuser may exhibit remorse, but the violence often escalates over time.
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