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:

Suggesting that the client attend adult day care three times per week is incorrect. While social interaction is essential for the elderly, it does not address the specific needs of a client with type 2 diabetes mellitus. Moreover, attending adult day care may not necessarily promote diabetes management.

Choice B rationale:

Reviewing assisted living accommodations with the client is incorrect. Assisted living facilities might be suitable for some elderly individuals, but in this case, the client lives independently. There is no indication in the question stem that the client needs assisted living arrangements at this time.

Choice C rationale:

Discussing a long-term care referral for the client with the provider is incorrect. Long-term care facilities are designed for individuals who require extensive assistance with daily activities. There is no information in the question suggesting that the client's condition has deteriorated to the extent of needing long-term care.

Choice D rationale:

Instructing the client about the use of telehealth services is the correct intervention. Telehealth services, including remote monitoring of blood glucose levels, virtual consultations with healthcare providers, and medication management, can enhance diabetes management for elderly individuals living independently in rural areas. Telehealth provides access to healthcare professionals without the need for frequent travel, addressing the challenges faced by individuals residing in remote areas.

A. Hold hands folded below the waist after donning sterile gloves B. Pick up and pour solutions with the palm of the hand covering bottle labels C. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape D. Maintain sterile objects within the line of vision

Correct Answer is D

Explanation

Maintain sterile objects within the line of vision.

A. Hold hands folded below the waist after donning sterile gloves. This is incorrect because holding hands below the waist can contaminate the gloves with microorganisms from the floor or clothing.
B. Pick up and pour solutions with the palm of the hand covering bottle labels. This is incorrect because covering bottle labels can obscure important information such as expiration dates or ingredients.
C. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape. This is incorrect because the border of the sterile drape is considered contaminated and any sterile item that touches it becomes contaminated as well.
D. Maintain sterile objects within the line of vision. This is correct because keeping an eye on sterile objects ensures that they are not accidentally touched by nonsterile items or persons.

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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 community health nurse is developing a plan of care for an older adult client who has type 2 diabetes mellitus and lives independently in a rural area.Which of the following interventions should the nurse include?

Correct Answer is D

Explanation

A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique?

Correct Answer is D

Explanation

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