A nurse in a provider's office is assessing a school-age child who has a spiral fracture.
The parent of the child provides different accounts of the cause of the injury.
Which of the following actions should the nurse take first?

Report suspected abuse to Child Protective Services.

Determine the immediate safety needs of the child.

Request that the parent leave the room while interviewing the child.

Ask the child how the injury occurred.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Reporting suspected abuse to Child Protective Services is important when there are concerns of child abuse. However, in this scenario, the nurse's first priority should be to ensure the immediate safety and well-being of the child. Without assessing the child's safety, it would be premature to report abuse. Child Protective Services can be involved later if necessary.

Choice C rationale:

Requesting that the parent leave the room while interviewing the child can be a useful strategy when there are concerns about abuse or when the child needs to speak freely. However, this should not be the first action. Ensuring the child's immediate safety takes precedence.

Choice D rationale:

Asking the child how the injury occurred is important in gathering information, but it should not be the first action. Ensuring the child's safety is of primary importance, and this information can be gathered after immediate safety needs are addressed.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

The correct answer is D. Hyperthermia.

Choice A reason: Hyperglycemia, which is an elevated blood glucose level, is not typically a direct manifestation of alcohol withdrawal. Alcohol withdrawal can sometimes lead to poor oral intake or vomiting, which might indirectly affect blood sugar levels, but hyperglycemia itself is not a primary concern in the context of alcohol withdrawal.

Choice B reason: Decreased blood pressure During alcohol withdrawal, the sympathetic nervous system is often overactive, leading to symptoms such as increased blood pressure, rather than decreased. Therefore, decreased blood pressure is not a common manifestation of alcohol withdrawal. Normal blood pressure ranges for adults are systolic BP of 100-120mmHg and diastolic BP of 70-80mmHg.

Choice C reason: Decreased heart rate Similar to blood pressure, the heart rate typically increases during alcohol withdrawal due to sympathetic nervous system overactivity. A normal resting heart rate for adults ranges from 60 to 100 beats per minute (bpm). Decreased heart rate is not expected during alcohol withdrawal.

Choice D reason: Hyperthermia, or elevated body temperature, is a common symptom of alcohol withdrawal. This occurs as part of the body’s response to the sudden absence of alcohol, and can be a part of the withdrawal syndrome, which includes a range of symptoms from mild anxiety to severe complications like seizures. Normal body temperature ranges from 97°F (36.1°C) to 99°F (37.2°C).

A. Hemoglobin 16 g/dL. B. WBC Count 8,000/mm3. C. RBC Count 4.9 million/mm². D. Platelets 100,000/mm3.

Correct Answer is D

Explanation

Choice A rationale:

Hemoglobin levels at 16 g/dL are within the normal range for an adult, so there is no need to report this result to the provider.

Choice B rationale:

A white blood cell (WBC) count of 8,000/mm3 is within the normal range, and there is no need to report this result to the provider.

Choice C rationale:

An RBC count of 4.9 million/mm² is within the normal range for adults, so it does not require reporting to the provider.

Choice D rationale:

A platelet count of 100,000/mm3 is below the normal range (typically 150,000-450,000/mm3). This lower platelet count can increase the risk of bleeding and may be associated with clonazepam use. Therefore, it should be reported to the provider for further evaluation and potential adjustment of the medication.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse in a provider's office is assessing a school-age child who has a spiral fracture.The parent of the child provides different accounts of the cause of the injury.Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations?

Correct Answer is D

Explanation

A nurse is reviewing the laboratory report of a client who has a panic disorder and is taking clonazepam.Which of the following laboratory results should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?

A nurse is reviewing the medical record of a client who is to begin taking aripiprazole.The nurse should identify that which of the following findings is a contraindication for aripiprazole therapy?

A nurse is caring for a client who has borderline personality disorder.Which of the following actions should the nurse take?

A nurse is assessing a client who has anorexia nervosa.Which of the following findings should the nurse expect? (Select all that apply.).

A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect?

A nurse is caring for a client who has a binge eating disorder.Which of the following actions should the nurse take?

A nurse in a provider's office is assessing a school-age child who has a spiral fracture.The parent of the child provides different accounts of the cause of the injury.Which of the following actions should the nurse take first?

A nurse is caring for a client who receives lamotrigine daily for bipolar disorder and reports a rash on his arm. Which of the following actions should the nurse take?

A nurse in a provider's office is assessing a school-age child who has a spiral fracture.
The parent of the child provides different accounts of the cause of the injury.
Which of the following actions should the nurse take first?