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 D

Explanation

Choice A reason: Opisthotonos is a severe arching of the back with hyperextension of the neck and limbs due to intense muscle spasms, often linked to tetanus or severe meningitis. It does not involve the specific arm adduction and foot plantar flexion with internal rotation described. This posture is unrelated to the neurological damage indicated, as it reflects a different pathological mechanism.

Choice B reason: Flaccid quadriplegia involves complete loss of muscle tone and voluntary movement in all four limbs, typically from spinal cord injury or neuromuscular disorders. The patient’s rigid arm adduction and plantar flexion indicate active muscle contraction, not flaccidity, making this an incorrect descriptor for the observed posture.

Choice C reason: Decorticate rigidity features arm flexion, clenched fists, and extended legs, typically due to cerebral cortex or internal capsule damage above the brainstem. The patient’s arm adduction and foot plantar flexion with internal rotation do not match this pattern, as decorticate posture lacks the internal rotation component.

Choice D reason: Decerebrate rigidity is marked by arm adduction, extension, and internal rotation, with legs extended and feet plantar flexed, as observed. This results from severe brainstem injury below the midbrain, disrupting corticospinal and vestibulospinal tracts, leading to unopposed extensor activity, accurately describing the patient’s posture.

A. Low parity B. Endometriosis C. Multiple sexual partners D. Obesity

Correct Answer is C

Explanation

Choice A reason: Low parity (few pregnancies) is not a primary risk factor for cervical cancer; high parity may be. Multiple sexual partners increase HPV exposure, the main cause, so this is incorrect.

Choice B reason: Endometriosis affects the uterus, not the cervix, and isn’t linked to cervical cancer. HPV from multiple partners is the key risk, so this is incorrect for the discussion.

Choice C reason: Multiple sexual partners increase the risk of HPV infection, the primary cause of cervical cancer. This is the most significant risk factor, making it the correct focus for teaching teens.

Choice D reason: Obesity is linked to some cancers but not strongly to cervical cancer. HPV exposure via multiple partners is the dominant risk, so this is incorrect for the nurse’s discussion.

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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

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Correct Answer is D

Explanation

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Correct Answer is C

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