A 5-month-old infant presents to the ED with right upper arm swelling, and a fracture is suspected. The mother first told the triage nurse that the infant rolled off the changing table during a diaper change, and later said the infant rolled off the couch when the doorbell rang. What knowledge guides the nurse in planning the next steps?
Infant bones are prone to fractures.
The focus should be on the injury not how it occurred.
Inconsistencies in how injury occurred may indicate child maltreatment.
Parents don't remember details when they are under stress.
The Correct Answer is C
Choice A reason: This is not the correct answer because infant bones are not prone to fractures. They are more flexible and resilient than adult bones, and require more force to break.
Choice B reason: This is not the correct answer because the focus should not be only on the injury, but also on how it occurred. The nurse should assess the mechanism of injury and the history of the child and the family for any signs of abuse or neglect.
Choice C reason: This is the correct answer because inconsistencies in how injury occurred may indicate child maltreatment. The nurse should be alert for any discrepancies or changes in the story, or any explanations that do not match the type or severity of the injury.
Choice D reason: This is not the correct answer because parents don't necessarily forget details when they are under stress. They may be anxious or emotional, but they should still be able to provide a consistent and coherent account of what happened.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The child's current vital signs are consistent with vital signs over the past 4 hours. This does not indicate that the child is in pain, as the vital signs may be within normal range or stable.
Choice B reason: The child becomes quiet when held and cuddled. This may indicate that the child is comforted by the nurse's presence and touch, not that the child is in pain.
Choice C reason: The child has just returned from the recovery room. This may indicate that the child is still under the influence of anesthesia or sedation, not that the child is in pain.
Choice D reason: The child is lying rigidly in bed and not moving. This is a sign of pain in children, as they may try to avoid movement or stimulation that could worsen their pain. The nurse should assess the child's pain level and administer pain medication as prescribed.
Correct Answer is D
Explanation
Choice A reason: This is not a good intervention because it disregards the parent's and the child's religious beliefs and values. It may also imply that the nurse knows better than the parent what is best for the child.
Choice B reason: This is not a necessary intervention because it does not address the immediate issue of the child's nutrition. It may also suggest that the nurse thinks the parent needs spiritual guidance or counseling.
Choice C reason: This is not a respectful intervention because it violates the parent's and the child's right to follow their dietary rules. It may also cause the parent and the child to feel guilty or conflicted.
Choice D reason: This is the best intervention because it honors the parent's and the child's preferences and practices. It also ensures that the child receives adequate and appropriate nutrition.
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