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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administering ketorolac does not require specific timing in relation to meals. It can be given with or without food, but the key considerations are related to the drug’s effects rather than meal timing.
B. Ketorolac does not require peak and trough serum level monitoring. This practice is more relevant for medications with narrow therapeutic ranges or those requiring precise dosage adjustments, which is not the case for ketorolac.
C. Observing for involuntary movements of the lips and tongue is not a primary concern for ketorolac therapy. This is more relevant to medications like antipsychotics that can cause extrapyramidal symptoms.
D. Assessing the skin daily for signs of bleeding is crucial because ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding due to its effects on platelet function and gastrointestinal mucosa.
Correct Answer is D
Explanation
A. Monitoring daily sodium intake is important for managing AKI, but it is not the immediate priority when addressing acute changes in heart rate and blood pressure.
B. Recording usual eating patterns is not relevant to the immediate concern of elevated heart rate and blood pressure in the context of AKI.
C. Documenting abdominal girth is relevant for assessing fluid status and potential complications like ascites, but it is not the first priority for addressing the acute symptoms of elevated heart rate and blood pressure.
D. Measuring and documenting urinary output is the most critical intervention because it provides essential information on kidney function and fluid balance, which directly impacts heart rate and blood pressure management in AKI.
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