A nurse is caring for a group of clients in a pediatric clinic. Which of the following clients is at highest risk for physical abuse?

An adolescent who is preparing to leave home for college

A school-age child who wants to go away to summer camp

A preschooler who is reluctant to share

A toddler who has cystic fibrosis

Answer and Explanation

The Correct Answer is D

A.   Adolescents who are preparing to leave home for college are generally more independent and have a higher level of verbal communication compared to younger children. They are less likely to be at high risk for physical abuse because they can potentially seek help or report abuse more readily.

B.   School-age children typically have better verbal communication skills and may express their desires and feelings more clearly compared to younger children. They are generally less vulnerable to physical abuse compared to younger children who may not be able to communicate their experiences as effectively.
C.   Preschoolers are at a higher risk for physical abuse compared to older children and adolescents. They are still developing verbal communication skills and may not be able to express their feelings or report abuse clearly. Their dependence on caregivers for basic needs and care also increases their vulnerability.
D.   Toddlers, especially those with chronic health conditions like cystic fibrosis, are particularly vulnerable to physical abuse. Their young age, dependency on caregivers for basic needs, limited verbal communication skills, and potential health challenges increase their risk. Caregivers may feel overwhelmed or stressed by the child's condition, which could potentially contribute to abusive behaviors.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. This is a proactive measure to enhance supervision and quick response to any signs of agitation, wandering, or attempts to get out of bed without assistance. Being closer to the nurses' station allows for more frequent monitoring and timely intervention to prevent falls.
B. Recreational therapy can play a significant role in enhancing the client's physical and cognitive abilities through tailored activities. Activities such as balance exercises, supervised walks, or engaging in structured programs can help improve mobility and reduce the risk of falls.
C. Lowering the window shade can reduce distractions and provide a calmer environment for the client. Excessive light or glare can sometimes contribute to confusion or disorientation in individuals with dementia. A more subdued environment can potentially decrease agitation and wandering behaviors, indirectly lowering the risk of falls.

D. The use of physical restraints, such as vest restraints, is generally discouraged in clients with dementia due to the potential for physical and psychological harm. Restraints can increase agitation, anxiety, and risk of injury, and they do not address the underlying causes of falls. The focus should be on environmental modifications, supervision, and non-pharmacological interventions.

A. "You should have asked for help." B. "Let's talk about how you were feeling." C. "I think you are experiencing guilt." D. "Everyone gets discouraged sometimes."

Correct Answer is B

Explanation

A. This response could come across as blaming or judgmental. It implies that the client made a mistake by not seeking help, which can exacerbate feelings of guilt or shame. It does not promote an open dialogue or supportive environment.
B. This response demonstrates empathy and a willingness to understand the client's emotional state leading up to the suicide attempt. It encourages open communication about the client's feelings and experiences, which is crucial for assessment and intervention planning.
C. This response suggests that the nurse is making assumptions about the client's emotions without allowing the client to express themselves fully. While guilt may be a common emotion after a suicide attempt, it's important for the nurse to first listen to the client's own description of their feelings.
D. This response minimizes the seriousness of the client's experience and emotions. It may invalidate the client's feelings of distress or despair that led to the suicide attempt. Such a response does not acknowledge the gravity of the situation or provide the necessary support.

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A nurse is caring for a group of clients in a pediatric clinic. Which of the following clients is at highest risk for physical abuse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has dementia and is experiencing an increased number of falls. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is obtaining a health history from a client who reports a recent suicide attempt. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is caring for a client who has depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?

A nurse is collecting data from a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is reinforcing teaching with a client who has bipolar disorder and has a new prescription for lithium. To address possible adverse effects, the nurse should include that which of the following laboratory values will be monitored while the client is taking this medication?

A nurse is collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?

A nurse is contributing to the plan of care for a client who has bipolar disorder and whose admission was voluntary. For which of the following interventions should the nurse confirm that the client has given informed consent?

A nurse is assisting in the care of a client who is scheduled to receive electroconvulsive therapy (ECT). Which of the following is the nurse's role during the informed consent process?

A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is collecting data from a client who reports drinking alcoholic beverages daily but has not consumed alcohol in the last 24 hr. Which of the following findings should the nurse identify as a manifestation of alcohol withdrawal?