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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition: Child maltreatment

Actions to take:

Interview the child separately from the parents

Ask a parent, away from the child

Parameters to monitor:

Signs of fear or apprehension from the child when either parent is present

Negative comments about child from either parent.

Rationale:

Potential Condition: Child Maltreatment

The client’s history of multiple injuries (bloody nose, sutures from hitting cabinet, and spiral fracture) in the context of the parent’s alcohol intoxication, slurring, and aggressive behavior raises concern for possible child maltreatment. The child’s statement about being "clumsy" and the observed scars also support the need for further investigation into possible abuse.

Actions to Take

Interview the child separately from the parents: To ensure the child can speak freely and report any concerns without the influence or presence of the parents, especially when maltreatment is suspected.

Ask a parent, away from the child: The parent should be interviewed privately to assess their behavior and any possible stressors or issues that could indicate abuse or neglect, especially considering their appearance and actions when visiting the child.

Parameters to Monitor

Signs of fear or apprehension from the child when either parent is present: This could indicate emotional distress or fear related to the parent’s behavior. It is important to observe how the child reacts to the presence of each parent during assessments.

Negative comments about the child from either parent: Verbal abuse or negative comments can be a red flag for emotional abuse or neglect. Careful attention should be paid to any signs of verbal maltreatment.

Potential Diagnoses: Incorrect Choices

Muscular Dystrophy: While this could explain a pattern of injury due to muscle weakness, it does not align with the history of multiple injuries caused by trauma or the current family dynamics.

Constipation: No evidence or symptoms supporting constipation were observed in the current assessment.

Strabismus: No direct evidence to suggest strabismus in the child’s history or exam.

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Correct Answer is C

Explanation

A. Abdominal pain rated 4 is moderate and should be managed but is not as immediately critical as hypotension.

B. A respiratory rate of 20/min is within normal limits for an adolescent and is not a priority finding.

C. Low blood pressure (hypotension) following blunt abdominal trauma is a concern for internal bleeding or hemorrhage. This is the priority finding and requires immediate intervention.

D. A heart rate of 72/min is normal and does not indicate immediate concern.

Correct Answer is ["5.3"]

Explanation

Rationale:

Convert pounds to kilograms: 28 lb / 2.2 = 12.7 kg (rounded to the nearest tenth)

Calculate the required dose: 12.7 kg * 10 mg/kg = 127 mg

Calculate the volume to administer: (127 mg / 120 mg) * 5 mL = 5.3 mL (rounded to the nearest tenth).

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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority?

Correct Answer is C

Explanation

A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["5.3"]

Explanation

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