A school nurse is examining the family history of a school-age child who has fractured their ulna for the second time. Which of the following findings place the child at risk for child abuse? (Select all that apply.)

Choice A rationale

Requesting a referral for a social worker may be beneficial in some cases, but it is not the most appropriate initial response. The nurse should first seek to understand the client’s feelings and concerns.

Choice B rationale

Discussing the client’s wishes with their provider is important, but it should come after understanding the client’s perspective. The nurse should respect the client’s autonomy and privacy.

Choice C rationale

This is the correct answer. The nurse should ask the client why they do not want to continue treatment. This allows the nurse to understand the client’s perspective, provide emotional support, and ensure that the client is making an informed decision.

Choice D rationale

Instructing the client to change their advance directives first is not the most appropriate initial response. While advance directives are important legal documents that express a client’s wishes for medical treatment, the nurse should first seek to understand the client’s feelings and concerns.

The correct answer is Choice B

Choice A rationale: Community-wide tuberculosis screenings are not the first-line response to a confirmed active case. While targeted screening may be appropriate for close contacts or high-risk groups, indiscriminate testing lacks cost-effectiveness and may overwhelm public health resources. Screening is a secondary prevention strategy, not an immediate containment measure. The priority is to initiate contact tracing and isolate the source. Therefore, this action is premature and not scientifically aligned with outbreak control protocols.

Choice B rationale: Tuberculosis is a notifiable disease under global public health regulations due to its airborne transmission and potential for outbreaks. Reporting to the public health department enables contact tracing, isolation protocols, and surveillance. This aligns with WHO and CDC guidelines for communicable disease control. Timely reporting activates epidemiological response systems and ensures legal compliance. It is the most immediate and scientifically justified action to prevent community spread and initiate containment measures.

Choice C rationale: Ensuring medication adherence is critical for individual treatment success and preventing drug resistance, especially with multidrug-resistant TB. However, this is a longitudinal management strategy rather than an immediate public health containment action. Directly observed therapy (DOT) is often used to support adherence, but it does not substitute for mandatory reporting or contact tracing. While essential for long-term control, it is not the first step in preventing community transmission.

Choice D rationale: Community education enhances awareness and reduces stigma, but it is a tertiary prevention strategy. It does not directly interrupt transmission or initiate containment. Education is valuable for long-term public health outcomes, but it lacks immediacy in halting spread from an active case. Scientific protocols prioritize identification, isolation, and reporting before educational outreach. Therefore, while beneficial, this action is not the most urgent or scientifically prioritized response.