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:
Raising all four side rails on the bed of a confused client can be considered a form of restraint, which should be avoided unless necessary for the safety of the patient. It may infringe on the client's autonomy and dignity.
Choice B Reason:
Electing not to care for a client who had an abortion is discriminatory and violates the principle of nonmaleficence (doing no harm). Nurses have a professional obligation to provide care to all patients regardless of their personal beliefs or circumstances.
Choice C Reason:
Withholding nutrition from a client with a do-not-resuscitate (DNR) order without clear medical indications goes against the principle of beneficence and could be considered unethical. Nutritional support is a basic aspect of care that should not be withheld unless it is medically indicated or aligns with the patient's wishes.
Choice D Reason:
A nurse administers prescribed opioids to a client who has a terminal illness and respiratory rate of 8/min represents ethical practice because administering prescribed opioids to a client with a terminal illness and a respiratory rate of 8/min is appropriate and aligns with the principle of beneficence. The nurse's action aims to alleviate the client's pain and suffering, which is essential in end-of-life care.
Correct Answer is A
Explanation
Choice A Reason:
"I will have a client who is on airborne precautions wear a mask when out of her room." This statement demonstrates understanding of airborne precautions. Clients on airborne precautions, such as those with tuberculosis or measles, should wear a mask when they leave their room to prevent the spread of infectious droplets.
Choice B Reason:
"I will place a client who has compromised immunity in a negative-pressure airflow room." While placing a client with compromised immunity in a negative-pressure airflow room may be appropriate in some cases to reduce the risk of exposure to pathogens, it is not a standard precaution and is not applicable to all clients with compromised immunity.
Choice C Reason:
"I will instruct visitors to wear a mask when visiting a client who is on contact precautions." This statement indicates an understanding of contact precautions. Visitors should wear appropriate personal protective equipment, such as gloves and gowns, when visiting clients on contact precautions to prevent the transmission of infectious agents.
Choice D Reason:
"I will wear an N95 respirator mask when caring for a client who is on droplet precautions." This statement demonstrates understanding of droplet precautions. Healthcare providers should wear a surgical mask when caring for clients on droplet precautions, as it helps prevent the transmission of respiratory droplets generated by the client through coughing, sneezing, or talking. N95 respirator masks are typically reserved for airborne precautions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.