The mother of an 8-year-old boy tells the practical nurse (PN) that he fell out of a tree and hurt his arm and shoulder. Which assessment finding should the PN note as the most significant indicator of possible child abuse?

The mother refuses to answer questions about family history.

The child has several abrasions on the chest and legs.

The child looks at the floor when answering the nurse's questions.

The mother's version of the injury is different from the child's version.

Answer and Explanation

The Correct Answer is D

In cases of suspected child abuse, inconsistencies or discrepancies between the child's account of the injury and the caregiver's version are concerning. It raises questions about the credibility of the explanation provided by the caregiver and suggests a possible attempt to conceal the true cause of the injury. Such discrepancies may indicate that the injury was intentionally inflicted or that the child is being coerced or influenced to provide a false account.
While the other assessment findings may raise some level of concern, they are not as significant as the discrepancy between the child's and mother's versions of the injury:
A. "The mother refuses to answer questions about family history." While this behavior may raise some suspicion or cause for further investigation, it alone does not conclusively indicate child abuse. It may be related to other factors such as privacy concerns or cultural differences.
B. "The child has several abrasions on the chest and legs." While the presence of abrasions can be concerning, they alone do not provide sufficient evidence of child abuse. Children are prone to injuries and can obtain abrasions during normal play and activities.
C. "The child looks at the floor when answering the nurse's questions." This behavior may suggest shyness, anxiety, or discomfort, but it is not a definitive indicator of child abuse. Some children may exhibit such behaviors due to their personality or other factors unrelated to abuse. It is important to consider the child's overall behavior and communication patterns in conjunction with other assessment findings.

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Correct Answer is B

Explanation

the practical nurse (PN) should engage in regular contact with the client who demonstrates an inability to communicate effectively. Regular contact helps establish a therapeutic relationship and provides opportunities for observation and assessment of the client's needs and behavior. It also helps the PN to build trust with the client over time.
The other options listed are not appropriate methods for interacting with a client with psychosis who has difficulty communicating effectively:
A. Discouraging group activities: Group activities can be beneficial for individuals with psychosis as they provide opportunities for social interaction, skill-building, and support. It is important to encourage participation in appropriate group activities that are tailored to the client's needs and abilities.
C. Touching the client when speaking: Touching the client without their consent may be perceived as invasive or threatening, especially for individuals with psychosis who may already have difficulties with sensory processing or boundaries. It is important to respect the client's personal space and communicate through verbal means, maintaining a respectful and
non-intrusive approach.
D. Establishing a no-harm contract: No-harm contracts are typically used in the context of suicidal or self-harming behaviors to promote safety and identify support systems. While safety is important, it is not directly related to the communication difficulties associated with psychosis. Instead, the focus should be on developing a therapeutic relationship and finding effective means of communication with the client.

A. Determine if the UAP would like assistance. B. Instruct the UAP to lower the bed for safety. C. Remain in the room to supervise the UAP. D. Assume care of the client immediately.

Correct Answer is B

Explanation

Bathing a bedfast client with the bed in a high position poses a potential risk to the client's safety. Lowering the bed to a safe height is important to prevent falls and injuries during the bathing procedure. The PN should promptly intervene and instruct the UAP to lower the bed to an appropriate level before continuing with the bathing process.
A. While remaining in the room to supervise the UAP is important, it should be done after ensuring the client's safety by lowering the bed. If the bed is not lowered, the risk of injury remains, and the PN should take immediate action to address the safety concern.
C. Determining if the UAP would like assistance is a valid consideration, but it should be secondary to addressing the safety issue of the bed height. Once the bed is lowered, the PN can assess if additional assistance is required and provide support accordingly.
D. Assuming care of the client immediately may be necessary if the client is in immediate danger or experiencing an urgent medical situation. However, in this case, the primary concern is addressing the safety issue related to the bed height, and the PN can address this by instructing the UAP to lower the bed.

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The mother of an 8-year-old boy tells the practical nurse (PN) that he fell out of a tree and hurt his arm and shoulder. Which assessment finding should the PN note as the most significant indicator of possible child abuse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is caring for a client with psychosis who demonstrates an inability to communicate effectively. Which method should the PN use to interact with the client?

Correct Answer is B

Explanation

The practical nurse (PN) observes unlicensed assistive personnel (UAP) bathing a bedfast client with the bed in a high position. Which action should the PN take?

Correct Answer is B

Explanation

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