The mother of a school-aged boy tells the practical nurse (PN) that he fell out of a tree and hurt his arm and shoulder. Which assessment should the practical nurse (PN) note as the most significant indicator of possible child abuse?
The injury description by the mother varies from the child's version.
The child looks at the floor when answering the nurse's questions.
The abrasions on the child's arms, legs, and chest have healed.
The mother describes in detail what she did for her injured child.
The Correct Answer is A
The injury description by the mother varies from the child's version.
Choice A rationale:
The practical nurse (PN) should note the significant indicator of possible child abuse, which is the discrepancy between the mother's description of the injury and the child's version. In cases of child abuse, perpetrators often provide inconsistent or conflicting explanations about how the injuries occurred, raising suspicion of maltreatment. This inconsistency can be a red flag for the PN to further assess the situation and, if necessary, report concerns to the appropriate authorities.
Choice B rationale:
While the child looking at the floor when answering questions might be a behavior worth noting, it alone is not a definitive indicator of child abuse. Children may exhibit various emotional responses for various reasons, and it requires further assessment to determine if there are signs of abuse.
Choice C rationale:
The healing of abrasions on the child's arms, legs, and chest does not necessarily indicate child abuse. Children are active and prone to minor injuries, which are a normal part of growing up. The PN should investigate further to determine the cause of the injuries.
Choice D rationale:
The mother describing in detail what she did for her injured child does not automatically suggest child abuse. It is essential for the PN to gather more information and conduct a comprehensive assessment before drawing any conclusions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D: Provide fluid and electrolyte replacement. Choice A rationale:
Isolating all infectious diarrhea victims is not the highest priority in this situation. While it is essential to prevent the spread of cholera, immediate medical intervention to treat those affected takes precedence.
Choice B rationale:
Administering prophylactic antibiotics as prescribed is not the highest priority because it focuses on prevention rather than treatment. In the case of a cholera outbreak, it is more critical to address the immediate needs of those already diagnosed.
Choice C rationale:
Administering cholera vaccines may be part of a preventive strategy, but it is not the highest priority during an active cholera outbreak. Vaccination takes time to develop immunity, and the focus should be on treating those already affected.
Choice D rationale:
Providing fluid and electrolyte replacement is the highest priority in managing cholera. Cholera is characterized by severe diarrhea and dehydration, which can lead to life-threatening complications. Promptly restoring fluids and electrolytes helps prevent shock and organ failure.
Correct Answer is D
Explanation
The correct answer is choice D. Cleanse the finger with soap and water.
Choice A rationale:
Explaining the occurrence to the client is not the first action the PN should take in this situation. The priority is to address the potential exposure to bloodborne pathogens and ensure the PN's safety.
Choice B rationale:
Observing the appearance of the injection site is important for routine assessment but is not the first action the PN should take after getting stuck with the used needle. Immediate action to clean the wound site is essential to reduce the risk of infection.
Choice C rationale:
While notifying the charge nurse about the incident is important, it should not be the first action taken. The PN's safety should be addressed first by cleansing the finger.
Choice D rationale:
The PN should first cleanse the finger with soap and water immediately after getting stuck with the used needle. This action helps reduce the risk of infection and contamination. After cleansing, the PN can follow the facility's protocol for reporting incidents and seek necessary medical attention if required.
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