A nurse is caring for four clients at an urgent care center. Which of the following clients should the nurse suspect has been physically abused?
3-year-old toddler with scalding burns over the face and chest reportedly sustained when the child pulled on tablecloth, spilling a cup of tea on himself.
6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle.
14-month-old toddler who is reportedly learning to walk and has several bruises on bony prominences of the lower legs and elbows.
9-month-old infant who sustained near drowning when he reportedly climbed into the tub and turned on the water.
The Correct Answer is B
Answer: B. 6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle.
Rationale:
A) 3-year-old toddler with scalding burns over the face and chest reportedly sustained when the child pulled on a tablecloth, spilling a cup of tea on himself:
Scalding burns in young children can be accidental, especially if the burns are consistent with typical patterns seen in such accidents. However, burns covering a large area, especially on the face and chest, may warrant further investigation to rule out abuse, particularly if the explanation seems inconsistent with the injury.
B) 6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle:
A spiral fracture is often associated with a twisting or rotational force, which is less common in typical bicycle accidents. Spiral fractures in children can be indicative of physical abuse, particularly if the explanation for the injury does not fit the typical mechanisms of injury associated with the reported activity. This type of fracture should prompt a thorough evaluation for possible abuse.
C) 14-month-old toddler who is reportedly learning to walk and has several bruises on bony prominences of the lower legs and elbows:
Bruises on bony prominences are common in toddlers who are learning to walk and are prone to minor falls. This pattern of bruising is usually consistent with typical developmental activities rather than abuse. However, repeated or severe bruising should still be evaluated carefully.
D) 9-month-old infant who sustained near drowning when he reportedly climbed into the tub and turned on the water:
While near drowning in an infant is a serious concern, it is less likely to be related to physical abuse if the explanation involves an accidental event. A thorough assessment is necessary to ensure safety and prevent further incidents, but the described scenario is not as indicative of abuse as a spiral fracture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse should determine the presence and degree of suicidal risk when caring for a client who has a depressive disorder, is in alcohol withdrawal, and reports a recent job loss. This intervention is the priority because the client is at increased risk of suicidal ideation or behavior due to the combination of depression, alcohol withdrawal, and recent job loss. Identifying support groups in the community for long-term treatment.
choice A and referring the client to a mental health care provider for evaluation and treatment.
choice D are important interventions but are not the priority at this time. Assisting the client to identify the negative effects of chemical dependency.
choice B may be necessary but does not address the priority concern of suicidal risk.
Correct Answer is C
Explanation
Constipation. Constipation is a common symptom of anorexia nervosa, as it can result from severe food restriction, dehydration, electrolyte imbalance, or laxative abuse. People with anorexia may also experience abdominal pain and bloating due to constipation.
Choice A. Hyperkalemia. Hyperkalemia is a condition of high potassium levels in the blood. It is not a typical symptom of anorexia, as people with anorexia tend to have low potassium levels due to vomiting, diuretic use, or inadequate intake.
Hyperkalemia can cause irregular heart rhythms, muscle weakness, and paralysis.
Choice B. Tachycardia. Tachycardia is a condition of fast heart rate. It is not a common symptom of anorexia, as people with anorexia tend to have bradycardia, which is a slow heart rate. Bradycardia can result from starvation, dehydration, or electrolyte imbalance and can lead to cardiac arrest. Tachycardia can occur in some cases of anorexia due to dehydration, anxiety or refeeding syndrome.
Choice D. Metrorrhagia. Metrorrhagia is a condition of irregular or excessive bleeding between menstrual periods. It is not a usual symptom of anorexia, as people with anorexia tend to have amenorrhea, which is the absence of
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