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

A.PRN (as needed) restraint prescriptions are not appropriate because restraints should only be used in situations where there is an immediate need for safety and all other methods of de-escalation have failed. Restraint use must be based on a current assessment of the client's behavior, and a specific prescription should be obtained each time restraints are applied.

B.Restraints should be removed every 2 hours to assess the client's skin, circulation, and range of motion, and to provide an opportunity for toileting, hydration, and movement. Prolonged use without breaks increases the risk of complications such as skin breakdown or impaired circulation.

C.Attach the restraint to the bed's side rails. Restraints should not be attached to the bed's side rails because it can lead to serious injuries if the client attempts to climb over the side rails while restrained. Instead, restraints should be attached to specific restraint ties or straps that are part of the bed frame.

D.The client's condition, including circulation, skin integrity, and behavior, should be monitored and documented every 15 minutes while restraints are in use. This frequent assessment helps ensure the client’s safety and comfort, and allows for early identification of potential complications.

A. The client reports a decrease in episodes of nausea. B. The client reports a decrease in breast tenderness. C. The client reports a decrease in headaches. D. The client reports a decrease in urinary frequency.

Correct Answer is A

Explanation

A is correct because ginger tea is an herbal remedy that has been shown to reduce nausea and vomiting in pregnancy.

B is incorrect because ginger tea does not have any effect on breast tenderness, which is a common symptom of pregnancy caused by hormonal changes.

C is incorrect because ginger tea does not have any effect on headaches, which can be caused by various factors such as dehydration, stress, or caffeine withdrawal in pregnancy.

D is incorrect because ginger tea does not have any effect on urinary frequency, which is a common symptom of pregnancy caused by increased blood volume and pressure on the bladder.

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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?

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