The mother of an 8-year-old boy tells the practical nurse (PN) that he fell out of a tree and hurt his arm and shoulder. Which assessment finding should the PN note as the most significant indicator of possible child abuse?
The mother refuses to answer questions about family history.
The child has several abrasions on the chest and legs.
The child looks at the floor when answering the nurse's questions.
The mother's version of the injury is different from the child's version.
The Correct Answer is D
In cases of suspected child abuse, inconsistencies or discrepancies between the child's account of the injury and the caregiver's version are concerning. It raises questions about the credibility of the explanation provided by the caregiver and suggests a possible attempt to conceal the true cause of the injury. Such discrepancies may indicate that the injury was intentionally inflicted or that the child is being coerced or influenced to provide a false account.
While the other assessment findings may raise some level of concern, they are not as significant as the discrepancy between the child's and mother's versions of the injury:
A. "The mother refuses to answer questions about family history." While this behavior may raise some suspicion or cause for further investigation, it alone does not conclusively indicate child abuse. It may be related to other factors such as privacy concerns or cultural differences.
B. "The child has several abrasions on the chest and legs." While the presence of abrasions can be concerning, they alone do not provide sufficient evidence of child abuse. Children are prone to injuries and can obtain abrasions during normal play and activities.
C. "The child looks at the floor when answering the nurse's questions." This behavior may suggest shyness, anxiety, or discomfort, but it is not a definitive indicator of child abuse. Some children may exhibit such behaviors due to their personality or other factors unrelated to abuse. It is important to consider the child's overall behavior and communication patterns in conjunction with other assessment findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. "I don't need to go to the hospital if I have another seizure unless it is a very long seizure or if I have several in a row." This statement demonstrates an understanding that certain characteristics of seizures, such as prolonged duration or multiple seizures in succession, may require medical attention and evaluation.
C. "I may never know why I started having seizures." This statement acknowledges the possibility that the underlying cause of the seizures may remain unknown. Seizure etiology can vary, and in some cases, the specific cause cannot be determined despite diagnostic tests.
D. "Having a medic alert bracelet might be a good idea, but it is up to me to decide if I want it or not." This statement recognizes the potential benefits of wearing a medic alert bracelet, which can provide crucial information about the client's condition in case of emergencies. It emphasizes the client's autonomy in making the decision, showing an understanding of the role and significance of the bracelet.
The following statement does not indicate understanding:
"There are really no lifestyle changes that I can do that will affect my risk of having another seizure." This statement is incorrect, as there are lifestyle modifications that can help reduce the risk of seizures, such as getting enough sleep, managing stress, avoiding triggers (if known), and taking prescribed medications as directed.
Regarding the statement "I can stop taking the phenytoin if I go for a while and don't have a seizure," it is not included in the given options.
Correct Answer is C
Explanation
When a client reports experiencing numbness and tingling in the extremities, it is crucial for the practical nurse (PN) to prioritize reporting the client's electrolyte levels to the healthcare provider. Electrolytes are essential minerals that help maintain the balance of fluids in the body and enable proper nerve and muscle function. Imbalances in electrolyte levels can lead to neurological symptoms, including numbness and tingling.
Options a, b, and d are not the correct priorities to report in this situation:
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