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 ["A","B","E"]
Explanation
A.This is a clear breach of confidentiality as sharing client information with individuals who are not part of the healthcare team and without the client's consent violates patient privacy.
B.Discussing a client’s condition in a public area where unauthorized individuals (like visitors) can overhear is a breach of confidentiality. Patient information should be discussed in private settings to protect the client's privacy.
C.This action is a good practice to protect patient information and does not breach confidentiality.
D.This is acceptable as long as proper protocols are followed, such as using secure fax lines and confirming that the receiving party is authorized to receive the information. This action does not inherently breach confidentiality.
E.If the nurse is not involved in the care of all those clients and does not have a legitimate reason to access that information, this action can also be considered a breach of confidentiality. Healthcare providers should only access information relevant to their role and responsibilities.
Correct Answer is C
Explanation
Choice A Reason:
Gauze is used to clean the wound from the outside to the center. This action does not demonstrate safe handling techniques. Wound cleaning should generally proceed from the least contaminated area to the most contaminated area, which is usually from the center of the wound outward, to avoid introducing microorganisms into the wound.
Choice B Reason:
The soiled dressing is placed on a nearby table. Placing the soiled dressing on a nearby table poses a risk of contamination to the surrounding environment and is not considered a safe practice. Soiled dressings should be properly disposed of in a designated biohazard waste container.
Choice C Reason:
This action demonstrates an understanding of infection control. Clean gloves should be discarded after removing the old dressing to prevent transferring any contaminants to the new dressing or sterile supplies.
Choice D Reason:
Sterile supplies should be opened only after the old dressing has been removed and the wound area has been cleaned.
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