A nurse suspects abuse when a 6-year-old child is taken to the emergency center for a traumatic injury. How should the nurse document the assessment findings?

Document what the child’s physician tells the nurse

Use the exact words the child has said to describe how the injury occurred

Document mainly what the parent has said about how the injury occurred

Focus only on photographs of the child’s injuries

Answer and Explanation

The Correct Answer is B

Choice A reason: Documenting only the physician’s statements is incomplete, as it omits direct observations and the child’s account. In suspected abuse, the nurse must record objective findings and the child’s narrative to ensure accurate reporting, making this inadequate.

Choice B reason: Using the child’s exact words ensures an objective, unbiased record of their account, critical in suspected abuse cases. This preserves the integrity of the child’s description for legal and medical evaluation, making it the most appropriate documentation method.

Choice C reason: Relying primarily on the parent’s account risks bias, especially in suspected abuse, as it may not reflect the true cause. The child’s narrative and objective findings are prioritized to ensure accurate reporting, making this an unreliable choice.

Choice D reason: Focusing only on photographs omits critical narrative and clinical details, such as the child’s account or physical findings. Comprehensive documentation, including the child’s words and observations, is essential in abuse cases, making this incomplete and incorrect.

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Correct Answer is A

Explanation

Choice A reason: In a conscious, alert, and oriented patient, the subjective report is the most reliable pain indicator, as pain is a subjective experience. The patient’s description of intensity, location, and quality directly reflects their perception, guided by neurological pain pathways, making this the gold standard.

Choice B reason: Vital signs like elevated heart rate or blood pressure may suggest pain but are nonspecific, as they can result from anxiety, exertion, or other conditions. They are less reliable than the patient’s verbal report, which directly conveys the pain experience.

Choice C reason: X-ray results may identify structural issues but cannot directly assess pain, a subjective sensation processed by the brain’s pain pathways. They are diagnostic, not experiential, making them unreliable for gauging pain in a conscious patient.

Choice D reason: Physical examination findings, like guarding or grimacing, are indirect pain indicators and less reliable than the patient’s subjective report. These signs may be absent or misleading in some patients, making the verbal description more accurate for pain assessment.

A. Let’s check with the physician to see if you are a candidate for this vaccine B. This vaccine is only for girls who have not yet started to become sexually active C. The vaccine cannot protect you now that you already have an HPV infection D. The HPV vaccine is for girls and women ages 9 to 26 years, so we can start that today

Correct Answer is C

Explanation

Choice A reason: Checking with the physician delays addressing the patient’s misunderstanding. The HPV vaccine does not treat existing infections or warts, as it is preventive, making this response less direct and informative than needed.

Choice B reason: The HPV vaccine is not limited to those not yet sexually active; it is recommended up to age 26, even for those with sexual history. This statement is outdated and incorrect, as vaccination can still benefit some with prior exposure.

Choice C reason: The HPV vaccine prevents new HPV infections but does not treat existing infections or genital warts, which are caused by specific HPV strains. Since the patient already has warts, the vaccine won’t help, making this the correct response.

Choice D reason: While the HPV vaccine is approved for ages 9–26, it does not treat existing infections or warts. Starting it without clarifying its preventive role misleads the patient, making this an incorrect and misleading response.

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A nurse suspects abuse when a 6-year-old child is taken to the emergency center for a traumatic injury. How should the nurse document the assessment findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a patient’s pain. Which would be the most reliable indicator of pain in a conscious, alert, and oriented patient?

Correct Answer is A

Explanation

During a health history, a 22-year-old woman asks, “Can I get that vaccine for human papilloma virus (HPV)? I have genital warts and I’d like them to go away!” What is the nurse’s best response?

Correct Answer is C

Explanation

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