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 B
Explanation
Choice A Reason:
Restraints should never be prescribed on an "as needed" basis (PRN). Each application of restraints requires a specific and current provider order.
Choice B Reason:
Apply the appropriate restraint, using a clove hitch or a square knot.When applying restraints, using a square knot isessential to ensure that the restraints remain secure but can be easily removed in case of an emergency. A square knot provides a balance between security and quick release when needed.
Choice C Reason:
Restraints should be tied to a non-movable part of the bed frame, not to a part that moves, to prevent injury to the client.
Choice D Reason:
Restraints should be checked and removed more frequently, typically every 2 hours, to assess the client’s skin integrity and circulation, and to provide range-of-motion exercises.
Correct Answer is A
Explanation
Choice A Reason:
A sufficient supply of personal protective equipment is appropriate. Bioterrorism events can involve the deliberate release of biological agents, such as bacteria, viruses, or toxins, with the intent to cause harm to individuals or populations. In such events, personal protective equipment (PPE) is critical for protecting healthcare workers and first responders from exposure to infectious agents and toxins. Adequate supplies of PPE, including masks, gloves, gowns, and eye protection, are essential to ensure the safety of healthcare workers and to prevent the spread of infection.
Choice B Reason:
A network for communication between staff members and families, is important for coordinating care and providing updates during a disaster, but it is not the highest priority when addressing immediate safety concerns related to a bioterrorism event.
Choice C Reason:
A mental health specialist on the response team, is important for providing support to individuals affected by the disaster, but it is not the highest priority during the initial response phase focused on safety and containment.
Choice D Reason:
A system for tracking client information, is important for maintaining continuity of care and tracking patient outcomes, but it is not the highest priority in the immediate response to a bioterrorism event when protecting healthcare workers and preventing further spread of infection is paramount.
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