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 B
Explanation
The Herpes zoster (shingles) vaccination is recommended for adults aged 60 years and older, regardless of whether they have had shingles or chicken pox before. The vaccine can reduce the risk of developing shingles and its complications, such as postherpetic neuralgia.
The other options are not correct because:
A. The vaccine is useful even if the person has had a case of shingles before, as shingles can recur in some people. The vaccine can prevent or reduce the severity of future episodes.
C. The person needs to get this vaccination even if they have had chickenpox, as shingles are caused by the reactivation of the same virus that causes chickenpox (varicella-zoster virus). The vaccine can boost the immunity against the virus and prevent it from reactivating.
D. The vaccination does not minimize outbreaks of cold sores, as cold sores are caused by a different virus (herpes simplex virus). The vaccine has no effect on this virus or its symptoms.
Correct Answer is A
Explanation
Observe how UAP obtains temperatures.
Choice A rationale:
The PN should first observe how the unlicensed assistive personnel (UAP) obtains temperatures using a tympanic thermometer. This step is essential to determine if there is an error in the technique or if the thermometer is malfunctioning. Correct technique and proper use of equipment are crucial to obtaining accurate and reliable temperature readings.
Choice B rationale:
While returning the thermometer for recalibration might be necessary if the thermometer is indeed faulty, it should not be the first action the PN takes. Observing the UAP's technique will help identify if the issue lies with the equipment or the individual's method.
Choice C rationale:
Demonstrating how to use the equipment might be helpful if the UAP is incorrectly using the thermometer. However, observing the UAP's technique first will help the PN identify if there is a need for retraining or recalibration.
Choice D rationale:
Showing the UAP how to chart temperatures is not the first priority when inconsistent readings are noted. Ensuring the accuracy of temperature measurements is essential for proper patient care and assessment.
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