A nurse working in an emergency department is caring for a group of clients. Which of the following clients should the nurse report for suspected maltreatment?
A toddler who cries whenever their parent enters the examination room
An adolescent who was admitted and refuses to speak to their parents
A preschooler who was previously toilet trained and now requires diapers in the hospital
A school-age child who has several abrasions on their lower legs
The Correct Answer is D
Choice A Reason:
A toddler who cries whenever their parent enters the examination room is incorrect. Toddlers may exhibit separation anxiety or fear of medical procedures, which is a common behavior in this age group.
Choice B Reason:
An adolescent who was admitted and refuses to speak to their parents is incorrect. Adolescents may exhibit behaviors such as withdrawal or reluctance to communicate with parents due to developmental changes, stress, or other factors unrelated to maltreatment.
Choice C Reason:
A preschooler who was previously toilet trained and now requires diapers in the hospital is incorrect. Regression in toileting skills is common in preschoolers during times of stress or illness, such as hospitalization. It does not necessarily indicate maltreatment but may be a response to the unfamiliar environment or medical condition.
Choice D Reason:
A school-age child who has several abrasions on their lower legs is correct. Abrasions on a school-age child's lower legs could potentially indicate physical abuse or neglect, especially if they are unexplained or inconsistent with the child's reported activities. Reporting such findings for further investigation is essential to ensure the safety and well-being of the child.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Checking the reading after the other nurse leaves the room is incorrect because it does not address the immediate need for accurate data and doesn't ensure that the initial readings were correct. It's important to act promptly to verify the accuracy of the readings to ensure patient safety.
Choice B Reason:
Documenting a pulse deficit of 16 beats per minute is incorrect. While there seems to be a difference of 16 beats per minute between the apical and radial pulses, it's essential to confirm this discrepancy with further assessment rather than immediately documenting it. Documentation should be based on accurate and verified data.
Choice C Reason:
Report the results of the deficit to the healthcare provider is incorrect. Reporting the results to the healthcare provider without confirming the accuracy of the initial readings may lead to unnecessary alarm or inappropriate interventions. It's important to ensure the data is reliable before escalating to the healthcare provider.
Choice D Reason:
Repeating the assessment to obtain another reading is correct because it allows the nurses to confirm the accuracy of the initial readings and ensure that there is indeed a pulse deficit. This action promotes patient safety by obtaining reliable data for appropriate intervention if needed. It's crucial to rule out any errors or discrepancies in the initial readings before taking further action or reporting to the healthcare provider.
Correct Answer is C
Explanation
Choice A Reason:
Replacing total parenteral nutrition solution bags every 48 hr is incorrect. Total parenteral nutrition (TPN) solution bags typically need to be replaced more frequently than every 48 hours to prevent bacterial contamination and ensure the integrity of the solution. However, the frequency of bag changes may vary depending on institutional protocols and specific patient needs.
Choice B Reason:
Replacing peripheral IV solution bags every 96 hr is incorrect. Peripheral IV solution bags may be changed less frequently than every 96 hours, as long as the solution remains sterile and the integrity of the infusion system is maintained. However, the frequency of bag changes may vary based on institutional policies and patient-specific factors.
Choice C Reason:
Changing peripheral IV primary tubing every 96 hr is correct. Changing peripheral IV primary tubing every 96 hours is a recommendation consistent with infection control guidelines and helps prevent contamination and bloodstream infections. This practice is cost-effective while ensuring patient safety.
Choice D Reason:
Changing total parenteral nutrition IV tubing every 48 hr is incorrect. Total parenteral nutrition (TPN) IV tubing typically needs to be changed more frequently than every 48 hours to prevent bacterial contamination and ensure the integrity of the TPN solution. However, the frequency of tubing changes may vary depending on institutional protocols and patient-specific factors.
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