Several children come to the Emergency Department for treatment. The situation that would cause the nurse to have the highest suspicion of child abuse would be:
Several visits of the same child with varied injuries.
A 5-year-old child who broke his arm and clings to mother crying.
A 1-year-old child who has a dislocated shoulder from arm swinging.
Repeated visits of the same child with middle ear infections.
The Correct Answer is A
a. Several visits of the same child with varied injuries.
Explanation of Choices
Choice A Reason: Several Visits of the Same Child with Varied Injuries
This scenario raises the highest suspicion of child abuse. Multiple visits with different injuries can indicate a pattern of harm rather than isolated accidents. Healthcare providers are trained to recognize that varied injuries over time, especially in different stages of healing, can be a red flag for abuse. This pattern suggests that the child may be experiencing ongoing harm rather than a single incident. The nurse should conduct a thorough assessment and consider involving child protective services to ensure the child’s safety.
Choice B Reason: A 5-Year-Old Child Who Broke His Arm and Clings to Mother Crying
While a broken arm in a child can be concerning, it is not uncommon for children to sustain such injuries during play or accidents. The child’s emotional response of clinging to the mother and crying is also typical for a young child in pain and distress. This scenario alone does not strongly indicate abuse without additional context or evidence. However, the nurse should still assess the situation carefully and consider any other signs or patterns that might suggest abuse.
Choice C Reason: A 1-Year-Old Child Who Has a Dislocated Shoulder from Arm Swinging
A dislocated shoulder in a 1-year-old is unusual and can be concerning. While it could result from an accident, such as arm swinging, it is also a potential sign of abuse, especially if the explanation does not match the injury. The nurse should investigate further, considering the child’s medical history and any other signs of potential abuse. However, this scenario alone does not provide as strong an indication of abuse as multiple varied injuries.
Choice D Reason: Repeated Visits of the Same Child with Middle Ear Infections
Repeated visits for middle ear infections are common in young children and are typically related to medical issues rather than abuse. Middle ear infections can occur frequently in children due to their anatomy and immune system development. This scenario does not raise immediate concerns about abuse unless there are other signs or patterns of harm. The nurse should focus on providing appropriate medical care and monitoring the child’s health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["5"]
Explanation
Step 1: Determine the concentration of Heparin in units per mL. 25,000 units ÷ 250 mL = 100 units per mL Result: 100
Step 2: Determine the rate in mL per hour needed to deliver 500 units per hour. 500 units ÷ 100 units per mL = 5 mL per hour Result: 5 mL per hour
The nurse should set the infusion pump to deliver at a rate of 5 mL per hour.
Correct Answer is B
Explanation
The correct answer is b. Administer oxygen via 100% nonrebreather and place an IV catheter to give naloxone.
Choice A Reason: Get the defibrillator to the patient’s bedside and open the crash cart
While having the defibrillator and crash cart ready is important in emergency situations, it is not the immediate priority in this scenario. The patient’s symptoms suggest opioid overdose, which requires immediate intervention to support breathing and reverse the effects of the opioid. The primary focus should be on ensuring adequate oxygenation and administering naloxone.
Choice B Reason: Administer oxygen via 100% nonrebreather and place an IV catheter to give naloxone
This is the correct answer. The patient’s blue-tinged lips, slowed respirations, and pinpoint pupils are indicative of opioid overdose. Administering oxygen via a 100% nonrebreather mask helps to ensure adequate oxygenation, while placing an IV catheter allows for the administration of naloxone, an opioid antagonist that can reverse the effects of the overdose. This intervention addresses the immediate life-threatening condition.
Choice C Reason: Administer naloxone intranasally if there is not an IV catheter in place
While administering naloxone intranasally is an appropriate alternative if IV access is not available, it is not the first priority. The initial focus should be on ensuring adequate oxygenation and establishing IV access for more effective administration of naloxone. If IV access cannot be quickly established, then intranasal naloxone can be used.
Choice D Reason: Contact the patient’s parents or legal guardian for consent to treat
Obtaining consent is important, but it is not the immediate priority in a life-threatening situation. The nurse’s primary responsibility is to stabilize the patient and address the acute medical emergency. Once the patient is stabilized, the nurse can then contact the parents or legal guardian for further consent and information.
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