A nurse on a medical-surgical unit is caring for a group of children. Which of the following findings should alert the nurse that one of the children is a potential victim of abuse?
A preschooler who has a BMI indicating obesity
A school-age child who cries when the nurse is giving him an injection
An adolescent who asks to stay in the hospital because he likes the room
A toddler who has multiple bruises on the shins of both legs and his parents report that he is clumsy
The Correct Answer is C
A. While childhood obesity is a health concern, it is not a specific indicator of abuse. Obesity can result from dietary habits, lack of physical activity, or medical conditions.
B. Fear of injections is common in children and is a typical developmental response. Crying during an injection is not an indicator of abuse and is expected behavior for many children.
C. While this finding alone does not confirm abuse, it may indicate an underlying issue in the adolescent's home environment. It requires further exploration through careful, open-ended questioning to assess for potential emotional or physical abuse or neglect.
D. Bruising on the shins of toddlers is common due to normal play and falls during development. The explanation provided by the parents aligns with typical toddler behavior and does not raise immediate concerns for abuse unless the bruises are in unusual locations (e.g., abdomen, back, or thighs).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Explanation:
A. Bathtub with rails:
Having a bathtub with rails is generally considered a safety measure, as it can assist the client in safely entering and exiting the bathtub. Rails provide support and stability, especially for older adults who may have mobility issues. Therefore, this finding is not typically identified as a safety risk.
B. Raised toilet seats:
Raised toilet seats can also be beneficial for older adults with mobility challenges, as they make it easier to sit down and stand up from the toilet. Similar to bathtub rails, raised toilet seats are considered a safety measure rather than a safety risk.
C. Electric cords behind furniture:
Electric cords behind furniture pose a tripping hazard, especially for older adults who may have reduced balance or vision. Trips and falls can lead to serious injuries, so it's important to keep walkways clear of obstacles, including electric cords. Therefore, this finding is identified as a safety risk.
D. Water heater temperature 54.4°C (130° F):
The recommended safe water heater temperature to prevent scalding injuries is typically around 48.9°C (120°F). A water heater temperature of 54.4°C (130°F) is higher than the recommended safe range and can increase the risk of scalding injuries, especially for older adults with sensitive skin or reduced sensation. Therefore, this finding is identified as a safety risk.
E. Throw rugs:
Throw rugs are common tripping hazards, particularly if they are not secured to the floor or have curled edges. Older adults can easily trip on throw rugs, leading to falls and injuries. It's recommended to remove or secure throw rugs to reduce the risk of falls, making this finding a safety risk.
Correct Answer is B
Explanation
Explanation:
A. It is not permissible because the provider should disclose laboratory results or findings to a client.
This statement is not accurate in this context. While it is true that healthcare providers are responsible for disclosing test results to clients, this responsibility is typically limited to the provider-patient relationship, not to family members of healthcare workers.
B. It is not permissible because there is no nurse-client relationship between the sibling and nurse.
This is the correct choice. In healthcare ethics and legal standards, privacy and confidentiality are essential. The nurse has a duty to maintain the confidentiality of patient information, and this duty extends to family members of patients. Since there is no official nurse-client relationship between the nurse and her sibling, accessing the sibling's diagnostic test results would violate the privacy and confidentiality rights of the sibling.
C. It is permissible because the sibling has paid for the service.
Payment for services does not override the principles of confidentiality and privacy in healthcare. Even if the sibling has paid for the service, it does not grant the nurse permission to access the sibling's medical information without proper authorization.
D. It is permissible because the client's sibling made the request.
The fact that the sibling made the request does not automatically make it permissible for the nurse to access the diagnostic test results. Confidentiality and privacy considerations are paramount in healthcare, and access to patient information is typically restricted to authorized individuals involved in the patient's care.
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