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A nurse is caring for four clients at an urgent care center. Which of the following clients should the nurse suspect has been physically abused?

3-year-old toddler with scalding burns over the face and chest reportedly sustained when the child pulled on tablecloth, spilling a cup of tea on himself.

6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle.

14-month-old toddler who is reportedly learning to walk and has several bruises on bony prominences of the lower legs and elbows.

9-month-old infant who sustained near drowning when he reportedly climbed into the tub and turned on the water.

Answer and Explanation

The Correct Answer is B

Answer: B. 6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle.

Rationale:

A) 3-year-old toddler with scalding burns over the face and chest reportedly sustained when the child pulled on a tablecloth, spilling a cup of tea on himself:

Scalding burns in young children can be accidental, especially if the burns are consistent with typical patterns seen in such accidents. However, burns covering a large area, especially on the face and chest, may warrant further investigation to rule out abuse, particularly if the explanation seems inconsistent with the injury.

B) 6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle:

A spiral fracture is often associated with a twisting or rotational force, which is less common in typical bicycle accidents. Spiral fractures in children can be indicative of physical abuse, particularly if the explanation for the injury does not fit the typical mechanisms of injury associated with the reported activity. This type of fracture should prompt a thorough evaluation for possible abuse.

C) 14-month-old toddler who is reportedly learning to walk and has several bruises on bony prominences of the lower legs and elbows:

Bruises on bony prominences are common in toddlers who are learning to walk and are prone to minor falls. This pattern of bruising is usually consistent with typical developmental activities rather than abuse. However, repeated or severe bruising should still be evaluated carefully.

D) 9-month-old infant who sustained near drowning when he reportedly climbed into the tub and turned on the water:

While near drowning in an infant is a serious concern, it is less likely to be related to physical abuse if the explanation involves an accidental event. A thorough assessment is necessary to ensure safety and prevent further incidents, but the described scenario is not as indicative of abuse as a spiral fracture.

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Correct Answer is B

Explanation

When an assistive personnel expresses concerns or vents about client behaviors, a therapeutic response is necessary. Asking the AP to explain or to further describe his or her thoughts, feelings, or concerns will allow the AP to reflect on these issues and help clarify any misconceptions or misunderstandings. The nurse's response should be nonjudgmental, noncritical, and focused on the AP's perceptions and feelings.

Option A is confrontational and Option C is inappropriate because it suggests that the AP is not spending enough time with the client.

Option D shifts responsibility for managing the client's behavior to the nurse instead of helping the AP reflect on his or her perception of the situation.

A. Whether the client is financially incapable of paying for prescribed medications. B. Whether the client is a danger to herself or others. C. Whether the client is unable to make arrangements to stay with someone. D. Whether the client is unwilling to accept that treatment is needed.

Correct Answer is B

Explanation

Whether the client is a danger to herself or others. When a client is involuntarily admitted to a mental health unit, they are held for an initial period of 72 hours for evaluation and treatment. Afterward, a determination must be made as to whether or not the client is still a danger to themselves or others to keep them in the hospital.

Choices A, C, and D do not address the primary concern of ongoing safety for the client and others.

For choice A, the client's financial status or their ability to pay for prescribed medications is not relevant to their safety or need for hospitalization.

For choice C, the client's ability to make arrangements to stay with someone is important for discharge planning but not for determining their need for ongoing hospitalization.

Finally, for choice D, whether the client is unwilling to accept treatment is important, but not the sole determining factor as to whether they are a danger to themselves or others.

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A nurse is caring for four clients at an urgent care center. Which of the following clients should the nurse suspect has been physically abused?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry because I think that the client might be doing it just to get attention." Which of the following responses by the nurse is therapeutic?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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