A nurse in a pediatric clinic is caring for a school-age child who has a perforated eardrum. The nurse suspects abuse. Which of the following actions should the nurse take?

Inform the parents that the findings must be reported to authorities.

Complete an incident report for risk management.

Interview the child about the suspected abuse with a parent present.

Avoid asking the child what caused the injury.

Answer and Explanation

The Correct Answer is A

Choice A reason: If a nurse suspects child abuse, they are legally required to report it to the appropriate authorities. Informing the parents that the findings must be reported is necessary to comply with mandatory reporting laws. This step ensures that the child receives the necessary protection and that the situation is investigated further by child protective services or law enforcement.

Choice B reason: Completing an incident report for risk management is an internal process used by healthcare facilities to document incidents that occur within the facility. While it is important to document the findings, this action alone does not fulfill the nurse's legal obligation to report suspected abuse to the authorities.

Choice C reason: Interviewing the child about the suspected abuse with a parent present may not be appropriate, especially if there is a possibility that the parent is the abuser. The presence of the parent could influence the child's responses and prevent them from speaking freely about the abuse. It is crucial to conduct the interview in a safe and supportive environment, often with a child protection professional or a social worker.

Choice D reason: Avoiding asking the child what caused the injury is not recommended in cases of suspected abuse. It is important for the nurse to gather as much information as possible about the cause of the injury. However, the nurse should approach the questioning in a sensitive and non-leading manner to avoid further traumatizing the child.

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Correct Answer is A

Explanation

Choice A reason: Low tolerance for frustration is a significant risk factor for becoming a perpetrator of child abuse. Individuals who have difficulty managing their frustration may be more likely to react impulsively and aggressively when faced with challenging situations. This inability to cope with frustration can lead to abusive behaviors, especially if the individual has not developed healthy coping mechanisms. The stress and demands of parenting can exacerbate these tendencies, increasing the risk of child abuse.

Choice B reason: Being involved in community activities is generally considered a protective factor rather than a risk factor. Participation in community activities can provide social support, reduce isolation, and offer positive role models. These factors can help individuals develop healthier coping strategies and reduce the likelihood of abusive behaviors. Therefore, involvement in community activities is not typically associated with an increased risk of becoming a perpetrator of child abuse.

Choice C reason: A submissive personality is not typically identified as a risk factor for becoming a perpetrator of child abuse. Submissive individuals are more likely to be passive and avoidant rather than aggressive and abusive. While personality traits can influence behavior, a submissive personality does not inherently increase the risk of perpetrating abuse. Other factors, such as a history of abuse, stress, and lack of support, are more relevant in assessing the risk of abusive behavior.

Choice D reason: The absence of impulsive behaviors is not a risk factor for becoming a perpetrator of child abuse. In fact, impulsivity is often associated with a higher risk of abusive behaviors. Individuals who lack impulsive behaviors are generally more capable of controlling their actions and responding to stress in a measured and thoughtful manner. Therefore, the absence of impulsive behaviors is not linked to an increased risk of child abuse.

A. Encourage the client to participate in a board game. B. Touch the client on the shoulder to console them. C. Bring a security guard whenever approaching the client. D. Use a calm, clear tone when speaking to the client.

Correct Answer is D

Explanation

Choice A reason: Encouraging the client to participate in a board game may be helpful for social interaction and engagement, but it is not the most appropriate intervention to address hostile verbal outbursts. Engaging in activities like board games can be beneficial for overall mental health, but the immediate issue of managing aggression requires more direct strategies.

Choice B reason: Touching the client on the shoulder to console them is not advisable in this situation. Physical contact can be misinterpreted by clients with schizophrenia and may escalate their agitation or aggression. It is important to maintain personal boundaries and use verbal communication to convey support and reassurance.

Choice C reason: Bringing a security guard whenever approaching the client can create an atmosphere of fear and mistrust. It is important to establish a therapeutic relationship built on trust and respect. While safety is a priority, using calm communication and de-escalation techniques is preferable to prevent hostile behavior.

Choice D reason: Using a calm, clear tone when speaking to the client is an effective intervention for managing hostile verbal outbursts. Calm communication helps de-escalate the situation and prevents further agitation. It shows the client that the nurse is in control and can provide a stable, reassuring presence, which is essential for building trust and maintaining a therapeutic environment.

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A nurse in a pediatric clinic is caring for a school-age child who has a perforated eardrum. The nurse suspects abuse. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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