A 5-month-old infant presents to the ED with right upper arm swelling, and a fracture is suspected. The mother first told the triage nurse that the infant rolled off the changing table during a diaper change, and later said the infant rolled off the couch when the doorbell rang. What knowledge guides the nurse in planning the next steps?
Infant bones are prone to fractures.
The focus should be on the injury not how it occurred.
Inconsistencies in how injury occurred may indicate child maltreatment.
Parents don't remember details when they are under stress.
The Correct Answer is C
Choice A reason: This is not the correct answer because infant bones are not prone to fractures. They are more flexible and resilient than adult bones, and require more force to break.
Choice B reason: This is not the correct answer because the focus should not be only on the injury, but also on how it occurred. The nurse should assess the mechanism of injury and the history of the child and the family for any signs of abuse or neglect.
Choice C reason: This is the correct answer because inconsistencies in how injury occurred may indicate child maltreatment. The nurse should be alert for any discrepancies or changes in the story, or any explanations that do not match the type or severity of the injury.
Choice D reason: This is not the correct answer because parents don't necessarily forget details when they are under stress. They may be anxious or emotional, but they should still be able to provide a consistent and coherent account of what happened.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This response is not appropriate because it does not address the mother's concern about antibiotics. It also implies that the nurse is making a medical decision for the child, which is beyond the scope of practice.
Choice B reason: This response is not appropriate because it does not provide any reassurance or education to the mother. It also sounds dismissive of the child's condition and the mother's worry.
Choice C reason: This response is not appropriate because it undermines the authority and judgment of the pediatrician. It also creates doubt and confusion in the mother's mind about the quality of care her child is receiving.
Choice D reason: This response is appropriate because it explains the rationale for not prescribing antibiotics for an ear infection. It also educates the mother about the difference between viral and bacterial infections and the appropriate use of antibiotics.
Correct Answer is D
Explanation
Choice A reason: Calling the physician is not the first action because it would delay the immediate intervention of oxygen administration, which is critical for a patient with hypoxia. The physician should be notified after initiating oxygen therapy and assessing the patient's condition.
Choice B reason: Placing the patient on 10 L/min oxygen per nasal cannula is not the first action because it is too high of a flow rate for a two-year-old patient, and it could cause oxygen toxicity or barotrauma. The appropriate oxygen delivery device and flow rate should be determined based on the patient's age, weight, and clinical status.
Choice C reason: Assessing the patient is not the first action because it would also delay the immediate intervention of oxygen administration. The patient's pulse oximetry reading indicates severe hypoxia, which requires prompt treatment to prevent organ damage or death. The patient should be assessed after initiating oxygen therapy and monitoring vital signs.
Choice D reason: Administering oxygen and monitoring vital signs while calling the physician is the correct answer because it provides the most effective and timely response to the patient's hypoxia. Oxygen administration improves the patient's oxygen saturation and tissue perfusion, while vital sign monitoring helps to evaluate the patient's response to therapy and identify any complications. Calling the physician informs them of the situation and allows them to order further interventions or tests as needed.
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