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","D","E"]

Explanation

The actions that are important for the nurse to take to help the client feel safe, secure, and in control of their own body are:

A. Prior to performing any intervention that requires touch, the nurse will ask permission.

This approach allows the client to feel respected and in control of their personal space. Asking for permission before any touch-related intervention acknowledges the client's autonomy and helps build trust.

D. The nurse will perform a continuous assessment of the client's anxiety level.

Continuous assessment of the client's anxiety level is important to identify any triggers or situations that may cause distress or feelings of unsafety. By monitoring the client's anxiety, the nurse can adjust care accordingly to promote a sense of security.

E. Have security present outside of the client's room to prevent anyone from coming in.

Having security present outside the client's room can provide an added layer of safety and reassurance for the client, especially if they have a history of abuse and may feel vulnerable or threatened.

It is not appropriate to:

B- Have the client perform all care independently and without assistance. The client may need assistance with certain care activities, and providing appropriate assistance can promote feelings of safety and trust.

C- Have two nurses present at all times to perform all care and procedures. While some situations may require additional staff for safety reasons, having two nurses present at all times for all care activities can be intrusive and may not respect the client's privacy and autonomy. It is essential to balance safety measures with promoting the client's sense of control and dignity.

A. In order to protect the rights of the client, the nurse should report the behavior to the supervisor. B. The client is entitled to have a relationship with anyone and the nurse should ignore the behavior. C. The nurse should confront the nurse and tell them the behavior must immediately stop. D. Discuss this with the client and tell them they are being emotionally manipulated.

Correct Answer is A

Explanation

When a nurse observes another nurse acting flirtatiously and bringing small gifts to a client in the behavioral health unit, it raises concerns about professional boundaries and the potential for unethical behavior. The priority action for the observing nurse is to protect the rights and well-being of the client.

Option A, reporting the behavior to the supervisor, is the appropriate course of action. Reporting the observed behavior to the supervisor ensures that the situation is investigated and addressed by the appropriate authorities within the healthcare facility. This action helps maintain the integrity of the therapeutic relationship between the client and healthcare team and protects the client from any potential exploitation or manipulation.

Options B, C and D are not appropriate actions:

B. Ignoring the behavior is not appropriate as it does not address the concerns about professional boundaries and the potential for unethical behavior. Ignoring such behavior may allow it to continue, potentially putting the client at risk.

C. Confronting the nurse directly without first reporting the behavior to the supervisor may not be the most appropriate course of action. It is essential to involve the appropriate authorities within the healthcare facility to conduct a proper investigation and address the situation professionally.

D. Discussing the situation with the client and making assumptions about emotional manipulation may not be appropriate or accurate. It is not the observing nurse's role to discuss such matters with the client. Instead, the appropriate course of action is to report the observed behavior to the supervisor or appropriate authority within the healthcare facility.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has been a victim of abuse since childhood. Which action(s) by the nurse is important so that the client feels safe, secure, and in control of their own body? Select all that apply. (Select All that Apply.)

Correct Answer is ["A","D","E"]

Explanation

A nurse observes another nurse acting flirtatiously and bringing small gifts, such as candy, to a client in the behavioral health unit. Which action is a priority by the observing nurse?

Correct Answer is A

Explanation

The nurse is working with another nurse in the emergency department (ED) when a client comes in stating they have been raped during a date. Which statement made by the other nurse privately requires immediate correction?

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The nurse approaches a client who looks very sad and is sitting alone crying. Which is the best response by the nurse in this situation?

The client with terminal lung cancer says to the nurse. "I really want to see my first grandchild born before I die. Is that too much to ask?" Which stage of grieving will the nurse document the client is experiencing?