A charge nurse is discussing qualitative and quantitative research with a newly licensed nurse. Which of the following statements should the charge nurse make?

Explanation:

A. Moist mucous membranes - This is unlikely in an end-of-life scenario. As death approaches, mucous membranes often become dry due to decreased fluid intake and decreased body function.

B. Tachycardia - Tachycardia, or a rapid heart rate, can be a common finding as death nears. It can result from various factors such as dehydration, fever, pain, or the body's response to stress.

C. Irregular respirations - Irregular respirations, including periods of apnea or agonal breathing (gasping, irregular, or shallow breaths), are typical findings in the end-of-life stage. These irregularities are part of the body's natural process as it shuts down.

D. Hypertension - Hypertension is less common in the end-of-life phase. Typically, blood pressure decreases as the body's systems begin to fail.

Explanation:

A. The child was brought to the facility 30 minutes after the injury occurred:

The timing of seeking medical attention alone may not necessarily indicate abuse. However, if there are inconsistencies in the reported mechanism of injury or if there is a delay in seeking medical care without a valid explanation, it can raise suspicion and warrant further investigation.

B. The parents report that the child injured herself by falling off the couch:

While falls are common causes of fractures in toddlers, spiral fractures are more commonly associated with twisting or torsional forces, which can raise concerns about non-accidental trauma. If the reported mechanism of injury does not align with the type of fracture or if there are inconsistencies in the history provided, it may indicate potential abuse.

C. The child begins to cry when her arm is examined by the provider:

It is common for children to cry or show discomfort during a physical examination, especially if they are in pain or feeling anxious. While this finding alone may not indicate abuse, it is essential to assess the child's behavior, pain response, and overall presentation for any additional signs or patterns of abuse.

D. The child's examination shows a single injury:

The presence of a single injury does not necessarily rule out abuse. Abusive injuries can be single or multiple, and the absence of other injuries does not negate the possibility of abuse. It is crucial to consider the context, history, and clinical findings comprehensively when evaluating for abuse.