A client is to receive a continuous Heparin infusion at s00 units per hour. Pharmacy supplies Heparin in a concentration of 25,000 units per 250mL of NSS.

Calculate the rate at which the nurse should set the infusion pump.

a. Several visits of the same child with varied injuries.

Explanation of Choices

Choice A Reason: Several Visits of the Same Child with Varied Injuries

This scenario raises the highest suspicion of child abuse. Multiple visits with different injuries can indicate a pattern of harm rather than isolated accidents. Healthcare providers are trained to recognize that varied injuries over time, especially in different stages of healing, can be a red flag for abuse. This pattern suggests that the child may be experiencing ongoing harm rather than a single incident. The nurse should conduct a thorough assessment and consider involving child protective services to ensure the child’s safety.

Choice B Reason: A 5-Year-Old Child Who Broke His Arm and Clings to Mother Crying

While a broken arm in a child can be concerning, it is not uncommon for children to sustain such injuries during play or accidents. The child’s emotional response of clinging to the mother and crying is also typical for a young child in pain and distress. This scenario alone does not strongly indicate abuse without additional context or evidence. However, the nurse should still assess the situation carefully and consider any other signs or patterns that might suggest abuse.

Choice C Reason: A 1-Year-Old Child Who Has a Dislocated Shoulder from Arm Swinging

A dislocated shoulder in a 1-year-old is unusual and can be concerning. While it could result from an accident, such as arm swinging, it is also a potential sign of abuse, especially if the explanation does not match the injury. The nurse should investigate further, considering the child’s medical history and any other signs of potential abuse. However, this scenario alone does not provide as strong an indication of abuse as multiple varied injuries.

Choice D Reason: Repeated Visits of the Same Child with Middle Ear Infections

Repeated visits for middle ear infections are common in young children and are typically related to medical issues rather than abuse. Middle ear infections can occur frequently in children due to their anatomy and immune system development. This scenario does not raise immediate concerns about abuse unless there are other signs or patterns of harm. The nurse should focus on providing appropriate medical care and monitoring the child’s health.

Choice A Reason:

Strong negative feelings interfere with assessment and judgment.

This statement is the most accurate explanation for why a nurse needs to be aware of their own feelings while working with a family experiencing domestic violence. Negative emotions such as anger, frustration, or sadness can cloud a nurse’s judgment and hinder their ability to objectively assess the situation. These feelings can lead to biased decision-making, which may compromise the quality of care provided to the victim. For instance, a nurse who feels anger towards the abuser might unconsciously project these feelings onto the victim, affecting their ability to offer unbiased support and intervention. Therefore, maintaining emotional awareness is crucial for ensuring accurate assessments and effective interventions.

Choice B Reason:

Awareness protects one’s own mental health.

While it is true that being aware of one’s feelings can help protect a nurse’s mental health, this statement does not directly address the impact of these feelings on the assessment and judgment process. Emotional awareness is important for self-care and preventing burnout, but the primary rationale for emotional awareness in the context of domestic violence is to ensure that the nurse can provide objective and effective care. Therefore, this choice is not as relevant to the specific question as choice A.

Choice C Reason:

Positive feelings promote the development of sympathy for clients.

Positive feelings such as empathy and compassion are important in nursing, but they can also lead to over-identification with the client, which may result in blurred professional boundaries. While sympathy can foster a supportive relationship, it is essential for nurses to maintain a balance between empathy and professional detachment to provide objective care. This statement does not fully capture the importance of emotional awareness in preventing negative feelings from interfering with assessment and judgment.

Choice D Reason:

Strong positive feelings lead to underinvolvement with the victim.

This statement is less accurate because strong positive feelings, such as empathy and compassion, are more likely to lead to over-involvement rather than underinvolvement. Over-involvement can result in blurred boundaries and difficulty maintaining professional objectivity. However, the primary concern in the context of domestic violence is the interference of negative feelings with assessment and judgment, making this choice less relevant to the question.