The school nurse is seeing a 7-year-old child in the clinic and is concerned with behaviors and physical indications that indicate the child is being sexually abused. Which is the priority action by the nurse?

The nurse must discuss the findings with the parents and give them the opportunity to explain.

Talk to the child and find out if they are experiencing sexual abuse or inappropriate touching.

The nurse should talk with another co-worker to be sure the nurse is correct about the assessment.

Accurately and thoroughly document the findings and report to the appropriate authorities.

Answer and Explanation

The Correct Answer is D

When a school nurse suspects that a child is being sexually abused, the priority action is to ensure the child's safety and well-being. Option D, accurately and thoroughly documenting the findings and reporting to the appropriate authorities, is the most critical step in protecting the child.

Child abuse, including sexual abuse, is a serious concern that requires immediate attention and intervention. In many jurisdictions, healthcare professionals, including school nurses, are mandated reporters, which means they are legally obligated to report suspected cases of child abuse to child protective services or other appropriate authorities.

Options A, B, and C are not appropriate as the child's safety is the top priority:

A. Discussing the findings with the parents and giving them the opportunity to explain could potentially place the child at further risk if the parents are involved in the abuse or are unwilling to address the situation.

B. Talking to the child and finding out if they are experiencing sexual abuse or inappropriate touching should not be the first step without involving child protective services or other appropriate authorities. The child may be frightened or reluctant to disclose abuse directly to the nurse, especially if the abuser is a family member or someone known to the child.

C. Talking with another co-worker to confirm the assessment may delay the necessary action and reporting to protect the child.

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Correct Answer is A

Explanation

The safety of both the client and others is the top priority in this situation. The client's aggressive behavior poses a significant risk, and immediate action is necessary. Calling for an emergency response from trained personnel, such as security or other staff members experienced in handling aggressive behavior, can help ensure the situation is properly managed and de-escalated in a safe manner.

Option B may not be appropriate in this situation, as trying to engage the client in verbal expression of anger while they are in an agitated and aggressive state can potentially escalate the situation further.

Option C is not recommended, as approaching the client in a confrontational manner may further escalate their anger and aggression.

Option D, while it may be beneficial in a different context and when the client is in a more stable state, is not appropriate when the client is actively engaged in aggressive behavior. The focus at this moment should be on ensuring the immediate safety of everyone involved.

A. "You may be in more physical danger after you leave them." B. "Batterers never change, so it would be best for you to leave." C. "If you leave, maybe your partner will see that they have to change their behavior." D. "If you don't leave. your partner will think you're going to continue to endure the abuse."

Correct Answer is C

Explanation

This response is the most supportive and empowering for the client. It acknowledges the client's agency in making decisions about their own life and relationship. It also conveys hope that leaving the abusive relationship may prompt the partner to realize the need to change their behavior. It does not impose judgment or make assumptions about the outcome, but instead, it recognizes the client's strength and potential for positive change.

Option A may instill fear and discourage the client from taking action to protect themselves.

option B generalizes that all batterers never change, which may not be true for all situations and individuals.

Option D may imply a threat or ultimatum, which is not appropriate and can be disempowering for the client. The most important aspect of supporting someone in an abusive relationship is to provide a non-judgmental, understanding, and empowering environment where they can explore their options and make decisions that are best for their safety and well-being.

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