A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse?

The child exhibits discomfort while walking

The child has thin extremities

The child has bruises on the upper back

The child is wearing a stained shirt

Answer and Explanation

The Correct Answer is A

A - This is correct because discomfort while walking can indicate genital trauma or infection, which are possible signs of sexual abuse.

B - This is incorrect because thin extremities can be caused by many factors, such as malnutrition, genetic disorders, or chronic diseases, that are not necessarily related to sexual abuse.

C - This is incorrect because bruises on the upper back can result from accidental injuries, such as falls or bumps, or from physical abuse, such as hitting or kicking, but not specifically from sexual abuse.

D - This is incorrect because a stained shirt can be due to poor hygiene, food spills, or environmental factors, but not necessarily from sexual abuse.

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Correct Answer is D

Explanation

Choice A rationale:

Instructing the client to "Lie down for 30 min after meals" is an inappropriate recommendation for managing heartburn during pregnancy. Lying down after meals allows stomach acid from flowing back into the esophagus, worseningheartburn symptoms.

Choice B rationale:

Eating a high-fat snack at bedtime is not advisable for managing heartburn. Fatty foods can relax the lower esophageal sphincter, allowing stomach acid to flow back into the esophagus and worsen heartburn symptoms. Avoiding high-fat snacks close to bedtime is a more appropriate recommendation.

Choice C rationale:

Sipping carbonated beverages throughout the day can exacerbate heartburn symptoms. Carbonated beverages, including sodas and sparkling water, can increase stomach acid and contribute to heartburn. Therefore, advising the client to avoid carbonated beverages is more appropriate for managing heartburn during pregnancy.

Choice D rationale:

Drinking hot herbal tea alleviates the heartburn symptoms and is recommended in pregnancy.

A. Select a 1-inch needle B. Use a 45° angle when inserting the needle C. Use the ventrogluteal site D. Pinch the skin up during injection

Correct Answer is C

Explanation

A. Incorrect. A 1-inch needle may not be long enough to reach the muscle layer in an obese client, which may result in subcutaneous injection and reduced absorption of the medication.
B. Incorrect. A 45° angle may not be appropriate for an IM injection, as it may cause the needle to enter at an oblique angle and miss the muscle layer or hit a bone or nerve.
C. Correct. The ventrogluteal site is preferred for IM injections in obese clients, as it has less subcutaneous fat and a large muscle mass that can accommodate larger volumes of medication.
D. Incorrect. Pinching the skin up during injection may cause the needle to enter at a shallow angle and deposit the medication in the subcutaneous tissue instead of the muscle layer.

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A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who is at 20 weeks of gestation about how to manage heartburn. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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