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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
A. Postpartum hemorrhage is incorrect because the client has scant lochia rubra and a firm fundus at the umbilicus, which indicate normal uterine involution and bleeding.
B. Seizures is correct because the client has signs of severe preeclampsia, such as headache, blurred vision, nausea, hyperreflexia, and clonus. These are indications of increased intracranial pressure and cerebral edema, which can lead to seizures or eclampsia.
C. Hyperglycemia is incorrect because there is no evidence of diabetes mellitus or gestational diabetes in the client's history or findings.
D. Hypoxemia is incorrect because there is no evidence of respiratory distress or impaired gas exchange in the client's history or findings.
E. Infection is incorrect because the client has no signs of infection, such as fever, malaise, foul-smelling lochia, or elevated WBC count.
Correct Answer is D
Explanation
A. This is not a correct procedure for client identification, but rather for blood compatibility. The nurse should check the client's blood type and crossmatch it against the blood product label, not the provider's orders.
B. This is not a reliable method of client identification, as the client may not know or remember their blood type correctly. The nurse should use two identifiers, such as name and date of birth, to confirm the client's identity.
C. This is not a relevant step for client identification, but rather for informed consent. The nurse should ensure that the client has signed an informed consent form before administering blood, but this does not verify that the blood product matches the client.
D. This is the correct procedure for client identification, as it involves two licensed nurses who independently check and confirm the client's identity and the blood product information, such as blood type, Rh factor, expiration date, and serial number.
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