A teacher suspects a child is being maltreated at home and takes them to the school nurse. Which of the following findings should the nurse report as an indication of possible maltreatment?
The child has recent onset of urinary incontinence.
The child receives free lunches at school.
The child has bruises on both knees.
The child reports having a toothache.
The Correct Answer is A
Choice A reason: The child has recent onset of urinary incontinence is a possible sign of maltreatment, as it may indicate sexual abuse, emotional trauma, or neglect. The school nurse should report this finding to the child protective services and follow up with the child and the family¹².
Choice B reason: The child receives free lunches at school is not a sign of maltreatment, but rather a socioeconomic indicator. The school nurse should not assume that the child is maltreated based on this factor alone, but rather assess the child for other signs and symptoms of abuse or neglect³.
Choice C reason: The child has bruises on both knees is not a sign of maltreatment, but rather a common injury among children who are active and playful. The school nurse should not report this finding unless there are other suspicious circumstances, such as inconsistent explanations, unusual locations, or patterns of bruises⁴.
Choice D reason: The child reports having a toothache is not a sign of maltreatment, but rather a health issue that may require dental care. The school nurse should not report this finding unless there are other signs of neglect, such as poor oral hygiene, lack of access to health care, or failure to follow up on referrals⁵.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Initiating topics of conversation that avoid the client's health status is not an appropriate intervention. The nurse should respect the client's wishes and preferences regarding the communication of their condition. The nurse should also provide emotional support and information as needed.
Choice B reason: Recommending the client seek out hospice services rather than seek treatment is not an appropriate intervention. The nurse should not impose their own values or beliefs on the client's decision-making process. The nurse should also respect the client's autonomy and right to self-determination.
Choice C reason: Providing quiet time during visits for prayer or meditation is an appropriate intervention. The nurse should acknowledge and support the client's spiritual needs and practices. The nurse should also facilitate the client's access to spiritual resources and counselors.
Choice D reason: Placing the client's name and medical condition on an online prayer chain is not an appropriate intervention. The nurse should protect the client's privacy and confidentiality and obtain their consent before sharing any personal information. The nurse should also respect the client's cultural and religious diversity and avoid any assumptions or stereotypes.
Correct Answer is B
Explanation
Choice A: The client’s insurance provides coverage for palliative care
This option is incorrect. While insurance coverage for palliative care is important, it is not a qualifying criterion for hospice care. Hospice care eligibility is primarily based on the patient’s medical condition and prognosis, not on insurance coverage.
Choice B: The client has declined additional life prolonging treatments
This option is correct. One of the key criteria for hospice care is that the patient must choose palliative care (comfort care) over curative treatments. This means the patient has decided to stop treatments aimed at prolonging life and instead focus on quality of life and symptom management.
Choice C: The client requires inpatient care due to lack of a caregiver
This option is incorrect. While the need for inpatient care can be a factor in the type of hospice services provided, it is not a criterion for qualifying for hospice care. Hospice care can be provided in various settings, including the patient’s home, regardless of caregiver availability.
Choice D: The client has documentation stating he has less than 12 months to live
This option is incorrect. The standard criterion for hospice care is a prognosis of six months or less to live if the disease follows its usual course. Documentation stating a life expectancy of less than 12 months does not meet the hospice eligibility requirement.
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