A woman and her live-in significant other come in the emergency department following a motor vehicle collision. Which finding should alert the nurse to assess for the possibility of domestic violence?

The woman is timid and speaks softly when asked about the accident.

spiral fracture on the woman's arm and wrist.

The woman is hyperventilating and appears to be in pain.

Fresh bruises on the woman's shoulder and chest.

Answer and Explanation

The Correct Answer is B

A. The woman is timid and speaks softly when asked about the accident: Timid behavior may suggest fear or anxiety, but it's nonspecific and may be due to trauma or emotional distress, not necessarily abuse.

B. Spiral fracture on the woman's arm and wrist: Spiral fractures occur from twisting injuries and are often associated with non-accidental trauma, especially when the injury doesn't match the reported mechanism.

C. The woman is hyperventilating and appears to be in pain: Hyperventilation and visible pain may indicate anxiety or physical injury, but they are expected after trauma and not unique to domestic violence.

D. Fresh bruises on the woman's shoulder and chest: Bruising is a possible sign of abuse, but bruises alone can result from a car accident. The type and location must be assessed in context.

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Correct Answer is C

Explanation

A. Tenderness: Tenderness during percussion could indicate an underlying issue, such as inflammation or infection, and is not a normal finding.

B. Pain: Pain during percussion may suggest problems like organ inflammation or distension and is not considered normal.

C. Musical and drumlike: This finding is normal and is often indicative of the presence of air or gas in the intestines, which is a common finding in older adults, especially those with less efficient digestion.

D. Absent sounds: Absent sounds could indicate bowel obstruction or other serious issues and are not a normal finding. Normal percussive sounds should be heard.

A. Facilitate a consultation for speech therapy. B. Arrange for daily home care assistance. C. Use pictures and gestures to communicate. D. Initiate passive range of motion exercises.

Correct Answer is A

Explanation

A. Facilitate a consultation for speech therapy: Aphasia and difficulty swallowing are common after a CVA. A speech therapist can assess and provide interventions to address both speech and swallowing issues, improving communication and reducing the risk of aspiration or choking.

B. Arrange for daily home care assistance: While home care assistance may be necessary later, the immediate priority is addressing the client's communication and swallowing difficulties through therapy and clinical interventions.

C. Use pictures and gestures to communicate: This is helpful for the client’s communication, but it should be seen as an adjunct to speech therapy, not a substitute. Speech therapy provides targeted interventions to improve both speech and swallowing.

D. Initiate passive range of motion exercises: Although range of motion exercises are important for preventing joint contractures and promoting mobility, addressing the client’s swallowing and communication issues is a more immediate priority.

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A woman and her live-in significant other come in the emergency department following a motor vehicle collision. Which finding should alert the nurse to assess for the possibility of domestic violence?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse completes percussion of the abdomen on an older adult client. Which finding is considered normal for this client?

Correct Answer is C

Explanation

An older adult client is referred to a rehabilitation facility following a cerebrovascular accident (CVA). The client is aphasic with left sided paresis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the client's plan of care?

Correct Answer is A

Explanation

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