A nurse in a community clinic is caring for a 20-month-old toddler who has spiral fractures of the right ulna and radius. Which of the following findings should the nurse recognize as a potential indication of abuse?
The child was brought to the facility 30 min after the injury occurred.
The child begins to cry when her arm is examined by the provider.
The parents report that the child injured herself by falling off the couch.
The child's examination shows a single injury.
The Correct Answer is C
The parents report that the child injured herself by falling off the couch.
A spiral fracture is a type of broken bone that occurs when a twisting force is applied to the bone. It is often seen in cases of child abuse, where the abuser grabs and twists the child's arm or leg.
Choice A is not correct because bringing the child to the facility soon after the injury does not rule out abuse. The abuser may have done so to avoid suspicion or to prevent further complications.
Choice B is not correct because crying when the arm is examined is a normal reaction for a child who is in pain and scared. It does not indicate abuse or neglect.
Choice C is correct because it is unlikely that a fall from a couch would cause a spiral fracture of the ulna and radius. These bones are strong and require a lot of force to break. A fall from a couch would more likely cause a greenstick fracture, which is a partial break of the bone that occurs in children with flexible bones.
Choice D is not correct because a single injury does not exclude abuse. The child may have been abused before and healed without medical attention, or the abuser may have targeted only one part of the body. A single injury should still raise suspicion and prompt further investigation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
If suspicion of abuse exists then reporting is mandatory.
Choice A is incorrect because civil liability does not depend on whether the abuse can be proven or not, but on whether the report was made in good faith or not.
Choice B is incorrect because evidence of abuse does not need to be collected prior to reporting, but only reasonable suspicion of abuse.
Choice C is incorrect because reporting is not voluntary for healthcare workers, but mandatory by law.
Choice D is correct because if suspicion of abuse exists then reporting is mandatory for any person, agency, organization, or entity with direct knowledge of child abuse or neglect.
Correct Answer is B
Explanation
The nurse should walk with the client at a gradually slowing pace when caring for a client with a generalized anxiety disorder who is rapidly pacing the corridors of the unit. This intervention provides the client with support and helps to prevent the client from becoming overwhelmed or getting injured. Allowing the client to pace alone until physically tired.
choice A can increase the sense of isolation and anxiety. Asking a small group of other clients to walk with the client.
choice C may be inappropriate or even harmful in some cases. Calmly instructing the client to stop pacing and sit in the dayroom.
choice D can be perceived by the client as dismissive and may escalate the anxiety level. The nurse should work with the client and their family to develop an individualized plan of care that meets the client's needs and goals.
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