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 C
Explanation
A. Delirium is an acute, often sudden onset of confusion and altered mental status, usually caused by an underlying medical condition or medication. It tends to fluctuate and is typically reversible — not consistent with the progressive and long-term decline described.
B. Amnesia refers specifically to memory loss, which can be caused by trauma, disease, or psychological factors, but it does not encompass the broader cognitive decline (such as impaired judgment, language, and executive function) seen in dementia.
C. Dementia is characterized by a gradual and progressive decline in memory, thinking, and reasoning skills over time. The two-year progression described in the question is typical of dementia, especially in older adults.
D. Parkinson’s disease is a neurodegenerative disorder primarily affecting movement.While it can be associated with dementia in later stages, the primary symptoms early on are related to motor function (e.g., tremors, rigidity), not memory and cognition.
Correct Answer is D
Explanation
A. Disabled family coping related to uneven distribution of power within a relationship is a potential diagnosis, but it doesn't address the immediate concern of the victim's physical safety. The primary issue here is the risk of further injury due to abuse.
B. Social Isolation, related to lack of community support system could be a contributing factor in some cases of intimate partner violence, but the primary concern in this case is the physical harm the victim is facing, rather than isolation.
C. Deficient knowledge, related to resources for escape from the abusive relationship is also relevant, as the victim expresses confusion about leaving. However, the more immediate issue here is the risk of injury due to ongoing abuse.
D. Risk for injury, related to partner's physical abuse when intoxicated is the most appropriate diagnosis because the victim is at immediate risk of harm from the partner’s behavior, especially when intoxicated. This is the most urgent and accurate concern.
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