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 C

Explanation

Choice A reason: The right 5th intercostal space at the sternal border is near the tricuspid valve, where murmurs from tricuspid regurgitation or stenosis are typically heard. Aortic valve stenosis murmurs, caused by turbulent flow through a narrowed aortic valve, are not prominent here, making this an incorrect assessment site.

Choice B reason: The right 2nd intercostal space at the sternal border is the aortic area, ideal for auscultating aortic valve stenosis murmurs. These murmurs are harsh, crescendo-decrescendo, and systolic, radiating to the carotid arteries due to turbulent blood flow through the stenosed aortic valve, making this the correct site.

Choice C reason: The left 5th intercostal space at the mid-clavicular line is the mitral valve area, where mitral regurgitation or stenosis murmurs are heard. Aortic valve stenosis murmurs originate from the aortic root and are not best detected here, rendering this choice incorrect.

Choice D reason: The left 2nd intercostal space at the mid-clavicular line is near the pulmonic valve, where pulmonic stenosis murmurs are auscultated. Aortic valve stenosis murmurs are not prominent in this area, as they are specific to the aortic region, making this an incorrect choice.

A. A 15-year-old female soccer player with a broken leg B. A 4-month-old with bruises on the arms C. An 8-year-old gymnast with a broken right arm D. A 2-year-old with bruises on the knees

Correct Answer is B

Explanation

Choice A reason: A 15-year-old soccer player with a broken leg likely sustained the injury during sports, a common occurrence. Bruises on a 4-month-old’s arms are more concerning, as infants are non-mobile and less likely to bruise accidentally, suggesting possible abuse.

Choice B reason: Bruises on a 4-month-old’s arms are highly concerning, as infants this age are not mobile and cannot self-injure. Such bruising may indicate non-accidental trauma or abuse, requiring immediate investigation, making this the most concerning patient for possible abuse.

Choice C reason: An 8-year-old gymnast with a broken arm may have been injured during gymnastics, a plausible accident. A 4-month-old with arm bruises is more alarming, as infants are less likely to bruise without external force, so this is less concerning.

Choice D reason: A 2-year-old with knee bruises is typical from active play or falls while learning to walk. Bruises on a non-mobile 4-month-old’s arms are more suspicious for abuse, making this less concerning than the infant’s situation.

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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

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