A nurse is providing care to a child during a routine wellness check-up. Which of the following client statements should indicate to the nurse that the client is at a higher risk for experiencing abuse and violence?

"I usually do well but I didn’t pass my last test."

"I think my parent is starting a new job this month."

"I don’t really have any role models."

"Sometimes I am not hungry when I wake up in the morning."

Answer and Explanation

The Correct Answer is C

Choice A reason: Struggling with a test or academic performance is common among children and does not directly indicate risk for abuse or violence. Academic difficulties can result from many factors such as learning challenges, stress, or lack of study time, but they are not a strong predictor of abuse.

Choice B reason: A parent starting a new job is not inherently linked to abuse risk. While changes in family dynamics or stressors can affect children, this statement does not suggest neglect or violence. Employment changes are normal life events and do not directly indicate abuse.

Choice C reason: Lacking role models can be a red flag for abuse or neglect. Children who do not identify supportive adults in their lives may be experiencing isolation, lack of guidance, or dysfunctional family environments. This absence of positive figures can increase vulnerability to abuse, as children without trusted adults may not have safe outlets to disclose mistreatment or seek help.

Choice D reason: Not feeling hungry in the morning is a common occurrence and does not necessarily indicate abuse. Appetite variations can be normal in children and are not a reliable marker of violence or neglect. Unless paired with other concerning signs such as malnutrition or food insecurity, this statement alone does not suggest abuse.

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Free Nursing Study Resources

Correct Answer is ["4"]

Explanation

Step 1 is: Identify the prescribed dose = 100 mg.

Step 2 is: Identify the available tablet strength = 25 mg.

Step 3 is: Divide the prescribed dose by the available strength.
100 ÷ 25 = 4.

Step 4 is: The nurse should administer 4 tablets with each dose.

A. Refer the client to a community support group. B. Instruct the client on how to leave the relationship. C. Implement the safety plan. D. Assess for risk of immediate harm to patient or children. E. The correct answer is: D)

Correct Answer is D

Explanation

Choice A reason: Referring the client to a community support group is an important intervention because it provides emotional support, resources, and connection with others who have experienced similar situations. However, this is not the immediate priority when abuse is reported. Before referral, the nurse must ensure that the client and any children are safe from imminent harm. Support groups are valuable for long-term coping and recovery but do not address urgent safety needs.

Choice B reason: Instructing the client on how to leave the relationship may be helpful, but it is not the priority. Leaving an abusive relationship can be dangerous if not carefully planned, and the nurse must first assess whether there is immediate risk of harm. Without this assessment, advising the client to leave could inadvertently increase danger, as abusers often escalate violence when they perceive loss of control.

Choice C reason: Implementing the safety plan is a critical step in protecting the client, but it comes after assessing the level of immediate danger. A safety plan includes strategies such as identifying safe places, emergency contacts, and escape routes. However, the nurse must first determine whether the client or children are currently at risk of harm before deciding which safety measures to activate.

Choice D reason: Assessing for risk of immediate harm to the patient or children is the priority because it directly addresses the most urgent concern—whether lives are in danger. This assessment guides all subsequent interventions, including safety planning, referrals, and education. Immediate risk assessment ensures that emergency measures, such as contacting law enforcement or child protective services, can be taken if necessary. It is the foundation of all other actions and aligns with the nurse’s duty to protect clients from harm.

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A nurse is providing care to a child during a routine wellness check-up. Which of the following client statements should indicate to the nurse that the client is at a higher risk for experiencing abuse and violence?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["4"]

Explanation

A nurse is caring for a client who has reported experiencing abuse at home. Which of the following actions should be a priority for the nurse?

Correct Answer is D

Explanation

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