A nurse is working in a school health clinic and suspects that a 9-year-old boy who comes for a routine physical examination is being neglected by his parents. The nurse notices that the boy is wearing dirty and torn clothes, has poor hygiene, and appears hungry and tired. The boy says that his parents are always busy and do not have time for him. Which of the following actions should the nurse take? (Select all that apply.)

Report the suspicion to the child protective services.

Document the findings and observations in the medical record.

Provide the boy with clean clothes, food, and a place to rest.

Educate the parents about the importance of meeting their child's basic needs.

Refer the boy to a counselor or a social worker.

Answer and Explanation

Correct Answer : A,B,C,D,E

Choice A Reason: The nurse should report the suspicion to the child protective services, which is a legal and ethical obligation for nurses who work with children. The nurse should follow the policies and procedures of his or her institution and state laws regarding reporting.

Choice B Reason: The nurse should document the findings and observations in the medical record, which is a legal and ethical obligation for nurses who work with children. The nurse should use objective and precise language to describe any signs or symptoms of neglect.

Choice C Reason: The nurse should provide the boy with clean clothes, food, and a place to rest, which is a legal and ethical obligation for nurses who work with children. The nurse should address the immediate needs of the boy and ensure his comfort and safety.

Choice D Reason: The nurse should educate the parents about the importance of meeting their child's basic needs, which is a legal and ethical obligation for nurses who work with children. The nurse should offer support and guidance to the parents and provide information about available resources and services.

Choice E Reason: The nurse should refer the boy to a counselor or a social worker, which is a legal and ethical obligation for nurses who work with children. The nurse should recognize his or her scope of practice and collaborate with other health care providers to ensure holistic care for the boy and his family.

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Correct Answer is B

Explanation

Choice A Reason: This question is not appropriate because it is leading and suggestive. It may influence or distort the boy's response by implying that his mother's boyfriend hit him with a belt.

Choice B Reason: This question is appropriate because it is open-ended and neutral. It allows the boy to describe his experience in his own words without imposing any assumptions or expectations.

Choice C Reason: This question is not appropriate because it is not directly related to the boy's bruises. It may be relevant to assess his living situation and caregivers, but it does not address the cause of his injury.

Choice D Reason: This question is not appropriate because it is not directly related to the boy's bruises. It may be relevant to assess his relationship with his mother's boyfriend, but it does not address the cause of his injury.

A. "You don't have to be afraid of telling me what happened. I'm here to help you." B. "You did the right thing by coming here today. I'm proud of you for being brave." C. "You are not alone in this situation. There are many other children who have gone through the same thing." D. "You are not to blame for what happened. It was not your fault."

Correct Answer is B

Explanation

The correct answer is B. The nurse should make a statement that expresses empathy, support, and praise for the child who is suspected of being sexually abused. This can help the child feel more comfortable, confident, and willing to share his or her experience.

Choice A Reason: This statement may sound reassuring, but it may also imply that the child has a Reason to be afraid or that the nurse already knows what happened. This may make the child feel more anxious or pressured to disclose something that he or she may not be ready to.

Choice B Reason: This statement expresses empathy, support, and praise for the child who is suspected of being sexually abused. This can help the child feel more comfortable, confident, and willing to share his or her experience.

Choice C Reason: This statement may intend to normalize the child's experience and make him or her feel less isolated, but it may also make the child feel more ashamed or stigmatized by implying that he or she is part of a group of victims.

Choice D Reason: This statement may intend to reduce the child's guilt or self-blame, but it may also suggest that the nurse has already made a judgment about what happened or who is responsible. This may make the child feel more defensive or reluctant to talk.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is interviewing a child who is suspected of being sexually abused by his uncle. The nurse notices that the child is avoiding eye contact, fidgeting with his hands, and giving vague answers. Which of the following statements should the nurse make to encourage the child to talk?

Correct Answer is B

Explanation

A nurse is assessing a child who is suspected of being physically abused by his father. Which of the following findings should the nurse report as possible indicators of abuse? (Select all that apply.)

A nurse is reviewing the legal and ethical aspects of reporting child abuse and neglect with a group of nursing students. The nurse explains that the legal obligation of the nurse to report child abuse and neglect is based on which of the following?

A nurse is caring for an 8-year-old boy who has been neglected by his father. The nurse observes that the boy is underweight, has poor hygiene, and shows signs of developmental delay. Which of the following nursing diagnoses is most appropriate for this child?

A nurse is assessing a child who is suspected of being physically abused by his father. Which of the following findings should the nurse report to the child protective services as a possible indicator of abuse?

A nurse is reviewing the legal and ethical obligations of reporting suspected or confirmed cases of child abuse and neglect. Which of the following information should the nurse include in the review?

A nurse is caring for a child who has been neglected by his parents. The nurse notices that the child is malnourished, dirty, and withdrawn. Which of the following statements by the nurse is appropriate to establish rapport with the child?