NCLEX-RNPsychosocial IntegrityMedium
A school nurse notices a 7-year-old child has multiple bruises in various stages of healing on the back and buttocks, areas not typically injured accidentally. The child says, "I fell down the stairs." What is the nurse's priority action?
- AAccept the child's explanation and document the bruises.
- BReport the suspected abuse to child protective services.
- CAsk the child to describe exactly how the fall occurred.
- DContact the child's parents to discuss the injuries.
Show answer & explanationAnswer & explanation
Correct answer: B. Report the suspected abuse to child protective services.
Nurses are mandatory reporters; bruises in unusual locations, in multiple stages of healing, with an inconsistent explanation are classic red flags for physical abuse, and suspicion alone (not proof) obligates the nurse to report to protective services.
Why the other options are wrong
- A. Accepting an inconsistent explanation for suspicious injuries fails to protect the child.
- C. Further interrogation is not the nurse's role and could be traumatic; reporting is the priority.
- D. Contacting parents first could alert a potential abuser and place the child at further risk.
Mandatory Reporting of Child Abuse
Nurses are legally required to report suspected child abuse or neglect to child protective services, regardless of certainty.
- Bruises in unusual locations (back, buttocks, ears) raise suspicion
- Multiple stages of healing suggest repeated injury
- Explanation inconsistent with injury pattern is a red flag
- Suspicion alone triggers mandatory reporting duty
Memory trick: Unusual spot + healing stages + mismatched story = report now.