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 D
Explanation
A. C-reactive protein level:
C-reactive protein (CRP) is a marker of inflammation but does not specifically identify the causative organism of an infection. While elevated CRP can suggest infection or inflammation, it doesn't provide the necessary information for treatment.
B. Serum blood glucose (BG) level:
Serum blood glucose levels are important to monitor in diabetic patients because high glucose levels can impair healing and increase the risk of infection. However, it does not directly help identify the causative organism in this situation.
C. Serum albumin:
Serum albumin reflects nutritional status and can indicate malnutrition or poor wound healing. While it may be relevant for healing, it is not the most immediate test to evaluate for infection.
D. Culture for sensitive organisms:
Given the red, swollen wound with drainage and foul odor, a wound culture is the most appropriate first step to identify the specific infectious organism. This will guide the healthcare provider in selecting the most appropriate antibiotic treatment.
Correct Answer is C
Explanation
The client is prescribed oxygen at 3 liters per minute, but the flowmeter shows that only 1 liter of oxygen is being delivered. This indicates an inadequate oxygen supply and immediate action is required to adjust the flow rate to meet the prescribed oxygen requirement. Failure to provide the appropriate oxygen flow rate can compromise the client's respiratory status and oxygenation. The PN should promptly increase the flow rate to the prescribed level to ensure the client receives the necessary oxygen therapy.
The other assessment findings mentioned are also important to note and address, but they do not require immediate action:
A. The client lying in a supine position in bed: While it is generally recommended for clients receiving oxygen therapy to be in an upright or semi-upright position, this finding does not require immediate action unless there are specific indications or contraindications related to the client's condition.
B. The cannula pressed snugly against the client's cheeks: The cannula should fit comfortably and securely on the client's face without causing discomfort or pressure areas. While this finding may require adjustment to ensure proper fit and comfort, it does not require immediate action unless it is causing harm or compromising oxygen delivery.
D. There is no humidifier attached to the delivery system: While a humidifier may be recommended to add moisture to the oxygen, its absence does not pose an immediate threat to the client's safety or require immediate action. The need for humidification depends on the client's condition and comfort level, and it can be addressed by attaching a humidifier if necessary.
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