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 {"dropdown-group-1":"D","dropdown-group-2":"D"}

Explanation

Cardiovascular abnormalities are a serious risk in clients with bulimia nervosa due to electrolyte imbalances, especially hypokalemia, which can lead to arrhythmias, weakened heart muscles, and potential heart failure. Hyponatremia (low sodium levels) can occur due to excessive vomiting, which leads to the loss of fluids and electrolytes, including sodium. Incorrect responses: Group 1: Hypoglycemia: Bulimia nervosa primarily causes electrolyte imbalances and acid-base disturbances due to vomiting, not significant alterations in blood sugar levels. Metabolic Acidosis: Vomiting leads to the loss of gastric acid, causing metabolic alkalosis. Hypotension: Hypotension could occur if the client experiences significant dehydration from vomiting. Hypotension would be a consequence of severe dehydration rather than a primary risk at this stage. Hyperglycemia: Hyperglycemia is not typically associated with bulimia nervosa or vomiting. It would be more relevant in conditions like diabetes. Group 2: Hyperkalemia: Hyperkalemia (high potassium) is unlikely in bulimia nervosa, where frequent vomiting usually leads to hypokalemia due to the loss of potassium in gastric secretions. Metabolic Acidosis: As mentioned before, vomiting leads to metabolic alkalosis, not acidosis, because of the loss of hydrochloric acid. Hypochloremia: Hypochloremia (low chloride levels) can occur with vomiting due to the loss of stomach acid, which contains chloride. While it is a possible outcome, metabolic alkalosis better captures the overall acid-base disturbance in the client.

A. The client is taking numerous deep, measured breaths. B. The client is calmly telling their partner that "the staff here is so controlling." C. The client is sitting with their head in their hands and appears to be crying. D. The client is pacing around the chair in which their partner is sitting.

Correct Answer is D

Explanation

A. The client is taking numerous deep, measured breaths. This is not an indication of potential violence, but rather a coping strategy to calm down and regulate emotions.

B. The client is calmly telling their partner that "the staff here is so controlling." This is not an indication of potential violence, but rather a expression of frustration or dissatisfaction with the treatment setting.

C. The client is sitting with their head in their hands and appears to be crying. This is not an indication of potential violence, but rather a sign of sadness or distress.

D. The client is pacing around the chair in which their partner is sitting. This is an indication of potential violence, as it shows restlessness, agitation, and possible intimidation of the partner.

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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 caring for a client who has bulimia nervosa. Exhibits The client is at risk for developing dropdown and dropdown

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"D"}

Explanation

A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence?

Correct Answer is D

Explanation

A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism?

A nurse is caring for a client who has a prescription for 1 unit of packed RBCs. Five minutes after beginning the transfusion, the client becomes febrile with chills. After stopping the transfusion, which of the following actions should the nurse take?

A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care?

A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?

A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge?

At a prenatal visit, a primigravida client confides to the practical nurse (PN) that her partner is abusive. Which information should the PN provide?

A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that the suctioning has been effective?