An emergency room nurse is assessing a toddler with multiple bruises and burns in various stages of healing. The nurse suspects that the toddler has been abused, however the physician disagrees. What is the nurse's priority at this time?

Nothing, as toddler's frequently fall and have multiple injuries in the home

Report the suspicions about abuse to the proper authorities (Child Protective Services)

Discuss the findings with the physician to collaborate and initiate a plan of care

Immediately verbally confront the caregivers about the suspicious injuries

Answer and Explanation

The Correct Answer is B

A. It is inappropriate to dismiss suspicions of abuse based on the assumption that toddlers frequently fall and have multiple injuries.
B. The nurse has a legal and ethical obligation to report suspicions of child abuse to the proper authorities, regardless of the physician's opinion. Reporting ensures that the child’s safety is prioritized and that an investigation can be conducted.
C. While discussing findings with the physician can be part of the process, it does not take precedence over the mandatory reporting of suspected abuse.
D. Confronting the caregivers directly is not appropriate and may put the child at further risk.

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Correct Answer is A

Explanation

A. Avoiding further palpation of the abdomen is crucial to prevent rupture of the tumor and potential spread of cancer cells.
B. Obtaining an accurate height and weight is important but not as critical as preventing tumor rupture.
C. Monitoring vital signs is essential but not the priority intervention in this context.
D. Assessing the urine for the presence of blood is important for overall assessment but not the most critical intervention compared to avoiding tumor rupture.

A. A blood pressure of 100/56 and a small weight gain B. A heart rate of 150 beats/minute with crying C. An apical pulse of 70 beats/minute and vomiting D. An hourly urine output of 45mL/hour

Correct Answer is C

Explanation

A. A blood pressure of 100/56 and a small weight gain may indicate fluid retention, but they are not immediately life-threatening.
B. A heart rate of 150 beats/minute with crying can be normal for a child of this age, especially during emotional distress.
C. An apical pulse of 70 beats/minute and vomiting are concerning because they may indicate digoxin toxicity. A low heart rate (bradycardia) in a child on digoxin requires immediate attention.
D. An hourly urine output of 45 mL/hour is adequate and not concerning in this context.

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An emergency room nurse is assessing a toddler with multiple bruises and burns in various stages of healing. The nurse suspects that the toddler has been abused, however the physician disagrees. What is the nurse's priority at this time?

Nursing Test Bank

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Explanation

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Correct Answer is C

Explanation

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