During a home health visit, a school-age child who has muscular dystrophy confides in the nurse that he was struck by his parents. Which of the following actions should the nurse take first?
Report the incident to local authorities
Check the child for injuries
Refer the parent to a social service agency
Enroll the parent in anger management classes
The Correct Answer is B
Choice A reason: Reporting the incident to local authorities is an important action, but it is not the first priority. The nurse should first assess the child's physical condition and provide any necessary care.
Choice B reason: Checking the child for injuries is the first action the nurse should take, as the child may have sustained physical harm from the abuse. The nurse should document any findings and report them to the appropriate authorities.
Choice C reason: Referring the parent to a social service agency is a helpful action, but it is not the first priority. The nurse should first ensure the child's safety and well-being.
Choice D reason: Enrolling the parent in anger management classes is a potential intervention, but it is not the first priority. The nurse should first address the immediate needs of the child and the family.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A child who has a BMI of 18 is not the highest priority, as it is within the normal range for children. BMI, or body mass index, is a measure of weight relative to height. A BMI of 18 is considered healthy for children aged 2 to 20 years, according to the Centers for Disease Control and Prevention (CDC). The nurse should monitor the child's growth and development and provide nutrition education as needed.
Choice B reason: An adolescent who has scoliosis is not the highest priority, as it is a common and usually mild condition. Scoliosis is a sideways curvature of the spine that affects about 3% of adolescents. Most cases of scoliosis are mild and do not require treatment, although some may need braces or surgery. The nurse should refer the adolescent to a specialist for further evaluation and management.
Choice C reason: An adolescent who has psoriasis is not the highest priority, as it is a chronic and non-contagious condition. Psoriasis is a skin disorder that causes red, scaly patches on the skin that may itch or burn. Psoriasis is not curable, but it can be controlled with medications, creams, or light therapy. The nurse should provide education and support to the adolescent and encourage them to seek medical care as needed.
Choice D reason: A child who has nits is the highest priority, as it indicates a parasitic infestation that can spread to others. Nits are the eggs of head lice, which are tiny insects that live on the scalp and feed on blood. Head lice can cause itching, irritation, and infection of the scalp. The nurse should isolate the child and notify the parents and the school staff. The nurse should also provide instructions on how to treat the infestation and prevent reinfestation.
Correct Answer is B
Explanation
Choice A reason: Presenting community education programs about stress management is not an example of tertiary prevention, but rather an example of primary prevention. Primary prevention aims to prevent violence from occurring in the first place by addressing the underlying causes and risk factors. Stress management is one of the strategies that can help reduce the potential for violent behavior.
Choice B reason: Developing resources for victims of abuse is an example of tertiary prevention. Tertiary prevention aims to reduce the consequences and complications of violence by providing treatment and rehabilitation for the survivors. Resources for victims of abuse may include counseling, shelter, legal aid, and support groups.
Choice C reason: Urging community leaders to make nonviolence a priority is not an example of tertiary prevention, but rather an example of secondary prevention. Secondary prevention aims to detect and intervene in violence as early as possible by identifying and responding to the warning signs and symptoms. Community leaders can play a role in promoting a culture of nonviolence and enforcing policies and laws that protect the victims and punish the perpetrators.
Choice D reason: Assessing for risk factors of intimate partner abuse during health examinations is not an example of tertiary prevention, but rather an example of secondary prevention. Secondary prevention aims to detect and intervene in violence as early as possible by identifying and responding to the warning signs and symptoms. Health examinations can provide an opportunity for screening and counseling the clients who may be at risk of or experiencing intimate partner abuse.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today