The practical nurse (PN) is assisting with data collection for clients who have been admitted to the emergency department. What clients should the PN report to the nurse for further intervention for possible family violence? Select all that apply.
A same-sex partner who broke her arm during a volleyball game.
A 3-year-old with multiple old fractures of the arms and torso.
A married man with multiple bruises to his hands and face.
A homeless man whose clothing is soiled and has a foul-smelling body odor.
An older adult with a skull fracture that occurred in an automobile collision.
Correct Answer : B,C
A. A broken arm from a volleyball game is an injury that is not necessarily indicative of family violence; it appears to be an accident.
B. Multiple old fractures in a young child may indicate possible abuse or family violence, as this pattern is concerning for potential neglect or physical harm.
C. Multiple bruises on the hands and face of a married man may suggest a pattern of domestic violence, which should be reported for further assessment.
D. Soiled clothing and foul body odor may indicate poor living conditions but are not specific indicators of family violence.
E. A skull fracture from an automobile collision is likely an accident, not necessarily indicative of family violence unless further evidence suggests abuse.
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Related Questions
Correct Answer is B
Explanation
A. Changing gloves is important for infection control, but in this context, the main issue is with the technique being used for the client's feet.
B. Soaking the feet is not recommended for clients with diabetes due to the risk of skin damage and infection; it is better to wash the feet gently and inspect them regularly.
C. Checking the client’s feet is important but should be done before washing or soaking, and the main concern here is not to soak the feet at all.
D. While testing water temperature is crucial for safe bathing, the more pressing issue here is the method of foot care for a diabetic client, which is not to soak the feet
Correct Answer is B
Explanation
A. Move away from the overbed table: This action can be done after the gloves are completely removed and disposed of. Moving away too early increases the risk of bumping into something and contaminating the gloves.
B. Sterile gloves are contaminated on the outside after performing a procedure like a dressing change. Pulling the glove down and everting it (turning it inside out) confines the contamination to the inside of the glove, reducing the risk of transferring germs to the hands or surrounding surfaces. This maintains a sterile field and minimizes the risk of healthcare-associated infections (HAIs).
C. Loosen the glove from the fingers: This might be the initial step while grasping the glove for removal, but the key is to maintain aseptic technique by keeping the outside of the glove contained throughout removal.
D. Raise the hands above waist level: Raising hands above the waist level increases the risk of contaminating the sterile field or nearby surfaces if the glove integrity is compromised.
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