Several children are seen in the ER for treatment of illnesses and injuries daily. The situation that would cause the nurse to have a high suspicion of child abuse would be:

a 1-year-old child who has a dislocated shoulder from arm swinging.

several visits of the same child with varied injuries.

a 5-year-old child who broke his arm and clings to mother crying

repeated visits of the same child with middle ear infections.

Answer and Explanation

The Correct Answer is B

B. Multiple visits of the same child with different injuries could be a significant red flag for possible child abuse. Patterns of repeated injuries or injuries inconsistent with the child's developmental stage or reported activities may indicate a pattern of maltreatment.
A. While accidental injuries can occur, a dislocated shoulder in a 1-year-old child from arm swinging seems unlikely and may warrant further investigation.
C. Breaking a bone, such as an arm, can occur accidentally during childhood play or activities and the behavior of the child clinging to the mother is expected in moments of pain.
D. Middle ear infections are common in childhood and typically do not raise suspicion of abuse on their own.

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Correct Answer is D

Explanation

D. Furosemide is a diuretic that works by increasing urine output, which in turn reduces fluid retention and swelling. By tracking the client's weight on a daily basis, the nurse can obtain a clear and consistent measure of how much fluid is being lost as a result of the medication.
A. Monitoring respiratory status but it may not be the most direct method for evaluating the effectiveness of furosemide in reducing peripheral edema.
B. Monitoring serum protein levels may provide information about the client's nutritional status and liver function, but it is not typically used as a direct measure of response to furosemide for peripheral edema.
C. Improvement in peripheral pulses may indicate a reduction in fluid overload and resolution of edema. However, changes in peripheral pulses may be influenced by factors other than diuresis, such as vascular disease or cardiac function.

A. Promoting activities that encourage self-reflection B. Identifying community resources C. Providing positive feedback D. Conveying an accepting attitude

Correct Answer is D

Explanation

D. Conveying an accepting attitude involves demonstrating empathy, respect, and non-judgmental acceptance of the client as they are. Clients with BPD often have a fear of rejection and abandonment, so feeling accepted and understood by the nurse is critical for building trust.
A. In the early stages of group intervention, clients may not yet feel comfortable engaging in deep self-reflection without first establishing trust in the nurse and the group.
B. Identifying community resources is important for comprehensive care, but it may not be the most essential aspect initially for establishing trust.
C. Providing positive feedback can help reinforce positive behaviors and build rapport with clients, but it may not be the most essential aspect initially for establishing trust.

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Several children are seen in the ER for treatment of illnesses and injuries daily. The situation that would cause the nurse to have a high suspicion of child abuse would be:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is administering furosemide 40 mg PO to a client who has peripheral edema. Which method would the nurse use to best evaluate the client's response to this medication?

Correct Answer is D

Explanation

The nurse is planning a psycho-education group for clients diagnosed with borderline personality disorder. The nurse understands that which aspect of group intervention is most essential initially to establish a trusting nurse-patient relationship?

Correct Answer is D

Explanation

The nurse is providing discharge instructions to the client taking disulfiram. Which of the following items should the nurse teach the client to avoid?

A client notifies a treatment team member of current suicidal ideation. Which nursing intervention would take priority?

A client with borderline personality disorder reported to the nurse in the clinic that they feel empty and anxious and wants to cut their arms. The nurse should:

A physician mentions to the nurse that a child with Attention Deficit-Hyperactivity Disorder (ADHD) will begin medication therapy. The nurse should prepare a plan to teach the family about:

A fifteen-year-old was referred to the adolescent mental health clinic after being arrested for prostitution. The client's parents reported that they have run away several times and is abusive towards them. The nurse should anticipate that the diagnosis will be:

The nurse is caring for a client after an endoscopy. The client is lethargic and not responding to verbal commands. The priority nursing action is to:

While talking to the school nurse, a child in third grade states, "My parents are away and I have not eaten for days. I am worried that my parents forgot about me and my little brother." The nurse would suspect what type of abuse?