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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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Accompany the client when ambulating. The nurse’s priority when caring for a client with alcohol use disorder and who is experiencing withdrawal symptoms is to prevent harm to the client. Physiologic manifestations of alcohol withdrawal syndrome include seizures, delirium tremens (DTs), and hallucinations. Therefore, ensuring the client’s safety is of the utmost importance. Accompanying the client when ambulating is the priority intervention as alcohol withdrawal may lead to ataxia, weakness, and dizziness which may lead to falls.

Choice A, placing the client in a private room, does not address the client’s physical needs.

Choice B, determining the client's level of disorientation, is something necessary to assess but not the priority.

Choice C, padding the side rails of the bed with towels, is not the priority intervention, and contributes little to the prevention of falls.

A. Initiate one-to-one nursing observation. B. Make a contract with the client for weight gain. C. Administer the Hamilton depression scale. D. Review the client's toxicology laboratory report.

Correct Answer is A

Explanation

initiate one-to-one nursing observation, as this is the most urgent intervention to ensure the safety of the client. The client has a history of depression, substance abuse, anorexia nervosa, and attempted suicide, which indicates that they are at high risk for harm to themselves. One-to-one observation involves an assigned staff member who will be with the client at all times, ensuring their safety and preventing any further self-harm attempts.

Choice B, making a contract with the client for weight gain, is not an appropriate first action as it does not address the client's immediate safety concerns.

Choice C, administering the Hamilton depression scale, may be important to assess the client's depressive symptoms but is not the most urgent priority.

Choice D, reviewing the client's toxicology laboratory report, may be necessary for the overall assessment of the client, but safety comes first.

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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?

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