A nurse working in an emergency department is caring for a group of clients. Which of the following clients should the nurse report for suspected maltreatment?
A toddler who cries whenever their parent enters the examination room
An adolescent who was admitted and refuses to speak to their parents
A preschooler who was previously toilet trained and now requires diapers in the hospital
A school-age child who has several abrasions on their lower legs
The Correct Answer is D
Choice A Reason:
A toddler who cries whenever their parent enters the examination room is incorrect. Toddlers may exhibit separation anxiety or fear of medical procedures, which is a common behavior in this age group.
Choice B Reason:
An adolescent who was admitted and refuses to speak to their parents is incorrect. Adolescents may exhibit behaviors such as withdrawal or reluctance to communicate with parents due to developmental changes, stress, or other factors unrelated to maltreatment.
Choice C Reason:
A preschooler who was previously toilet trained and now requires diapers in the hospital is incorrect. Regression in toileting skills is common in preschoolers during times of stress or illness, such as hospitalization. It does not necessarily indicate maltreatment but may be a response to the unfamiliar environment or medical condition.
Choice D Reason:
A school-age child who has several abrasions on their lower legs is correct. Abrasions on a school-age child's lower legs could potentially indicate physical abuse or neglect, especially if they are unexplained or inconsistent with the child's reported activities. Reporting such findings for further investigation is essential to ensure the safety and well-being of the child.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
A client who has Guillain-Barré syndrome and a tracheostomy is incorrect. Guillain-Barré syndrome can be a complex condition, especially when accompanied by a tracheostomy. Caring for a client with this condition requires knowledge and experience in managing respiratory and neurological complications. It may not be suitable for a newly licensed nurse who may require more experience to manage such complex care needs.
Choice B Reason:
A client who has a brain tumor and is admitted for chemotherapy is incorrect. Caring for a client with a brain tumor undergoing chemotherapy involves understanding the effects of both the tumor and the treatment on the client's neurological status and overall well-being. It may require advanced assessment skills and knowledge of potential complications. Assigning this client to a newly licensed nurse may not be appropriate without additional support and supervision.
Choice C Reason:
A client who has multiple sclerosis and ataxia is incorrect. Multiple sclerosis (MS) can present with various neurological symptoms, including ataxia, which affects coordination and balance. Managing the care of a client with MS and ataxia may require familiarity with the disease process, symptom management strategies, and potential complications. It may be more suitable for a nurse with some experience in neurological nursing.
Choice D Reason:
A client who sustained a concussion and is being monitored for complications is correct. Caring for a client with a concussion being monitored for complications is typically within the scope of practice for a newly licensed nurse. Monitoring for changes in neurological status, assessing for signs of increased intracranial pressure, and providing supportive care are tasks that can be managed by a newly licensed nurse under appropriate supervision.
Correct Answer is D
Explanation
Choice A Reason:
Reinforcing the potential consequences of not having advance directives on record is important, but the immediate priority is to ensure that the missing documentation is obtained.
Choice B Reason:
Reminding nurses to obtain advance directive information during the admission process is a proactive approach to preventing future instances of missing documentation. However, the priority now is to address the current gap in documentation for clients already admitted.
Choice C Reason:
Meeting with nursing staff to review the policy regarding advance directives can provide clarification and reinforcement of expectations, but again, the immediate priority is to address the missing documentation for current clients.
Choice D Reason:
Asking nurses who are caring for clients without this information in the medical record to obtain it. The priority action for the nurse manager is to ensure that advance directives, which are critical documents outlining a patient's wishes regarding medical treatment, are obtained for clients who currently lack documentation. This ensures that patients' preferences and choices regarding their care are respected, especially in critical situations.
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