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 A
Explanation
The correct answer is Choice A:
Assist in turning the client to one side. Choice A rationale:
When preparing a client with obstructive sleep apnea for sleep, the practical nurse (PN) should assist the client in turning to one side. This position is known as the lateral position and can be beneficial for clients with obstructive sleep apnea. Lying on one's side can help to reduce the likelihood of airway obstruction and minimize the occurrence of apnea (pauses in breathing) during sleep. This position promotes better airflow and can improve the client's overall sleep quality.
Choice B rationale:
Keeping oral suction equipment nearby (Choice B) might be appropriate for clients with respiratory issues or a risk of airway obstruction. However, it is not the best action for a client with obstructive sleep apnea. Sleep apnea primarily involves upper airway collapse, not excessive secretions or obstructions in the oral cavity.
Choice C rationale:
Offering to bring the client a sleeping pill (Choice C) is not an appropriate action for a client with obstructive sleep apnea. Sleep apnea is characterized by repeated episodes of blocked or restricted airflow during sleep. Sedative medications can further relax the muscles in the airway, worsening the condition and potentially leading to more severe apnea.
Choice D rationale:
Placing a cool air humidifier in the room (Choice D) may be helpful for clients who experience dryness or congestion in the airways during sleep. However, it is not specifically indicated for obstructive sleep apnea. While humidifiers can be beneficial for some sleep-related issues, they do not address the underlying cause of sleep apnea.
Correct Answer is B
Explanation
The correct answer is choice B: Monitor the client's hearing. Choice A rationale:
Observing the skin for a rash is not relevant to assessing for signs of ototoxicity. Aminoglycosides can cause skin reactions, but this is not a specific sign of ototoxicity.
Choice B rationale:
Monitoring the client's hearing is essential when administering aminoglycosides because these medications can cause ototoxicity, which is damage to the inner ear and auditory nerve leading to hearing loss or tinnitus. Regular hearing assessments can help detect any changes in hearing and prompt appropriate interventions.
Choice C rationale:
Measuring the urinary output is not directly related to assessing for ototoxicity.
Aminoglycosides can cause kidney toxicity, but this is a separate concern from ototoxicity. Choice D rationale:
Checking for changes in vision is not specifically associated with aminoglycoside administration. Vision changes are not a common side effect of these medications, so it would not be a primary assessment in this situation.
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