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: Bruises on the elbow are common in active children due to play or minor falls. They are typically not concerning unless accompanied by other suspicious signs. Abdominal bruising, however, is less common and may indicate trauma or abuse, making this less concerning.

Choice B reason: Forehead bruises are frequent in toddlers learning to walk, often from bumping into objects. While concerning if severe, they are less alarming than abdominal bruising, which is less typical and may suggest internal injury or abuse, so this is not the most concerning.

Choice C reason: Abdominal bruising in a 3-year-old is highly concerning, as it is uncommon in normal play and may indicate significant trauma, abuse, or internal injury. This location raises red flags for non-accidental injury, requiring urgent investigation, making it the most concerning bruise.

Choice D reason: Lower leg bruises are common in active children from running or minor injuries. They are less concerning than abdominal bruising, which is atypical and may signal serious trauma or abuse, so this is not the most concerning finding in this context.

A. Write a series of numbers. B. Recall four words told to him/her 10 minutes earlier. C. Verify information, such as mother’s maiden name. D. Name the past four presidents.

Correct Answer is B

Explanation

Choice A reason: Writing a series of numbers tests attention or working memory, not recent memory recall. Recalling words after a delay specifically assesses short-term memory, which is more relevant for a 70-year-old, so this is not the best method.

Choice B reason: Asking a patient to recall four words after 10 minutes directly tests recent memory, a key cognitive function in older adults. This method is standard in assessments like the Mini-Mental State Exam, making it the best choice for evaluating memory.

Choice C reason: Verifying information like a mother’s maiden name tests long-term memory, not recent recall. Recent memory involves retaining new information, so recalling words after a delay is more appropriate, making this incorrect.

Choice D reason: Naming past presidents relies on long-term memory and general knowledge, not recent memory. Recalling newly learned words after 10 minutes better assesses short-term memory, so this is not the best approach for recent memory.

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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 examining a 3-year-old child. Which bruise, if found, would be of most concern?

Correct Answer is C

Explanation

The best way to assess a 70-year-old patient’s recent memory recall is for the nurse to ask the patient to:

Correct Answer is B

Explanation

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