The nurse is caring for several patients on a pediatric unit. Which patient should the nurse be most concerned about possible abuse?

A 15-year-old female soccer player with a broken leg

A 4-month-old with bruises on the arms

An 8-year-old gymnast with a broken right arm

A 2-year-old with bruises on the knees

Answer and Explanation

The Correct Answer is B

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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Correct Answer is D

Explanation

Choice A reason: The submandibular glands are palpable below the mandible, but occipital glands do not exist as salivary glands. The occipital region relates to lymph nodes or muscles, not salivary structures, making this an incorrect pair for palpation.

Choice B reason: The parotid glands are palpable near the ears, but jugulodigastric refers to lymph nodes, not salivary glands. This misidentification of anatomical structures makes this pair incorrect for assessing salivary gland palpation.

Choice C reason: Occipital and submental regions do not contain salivary glands. Submental lymph nodes exist, but neither these nor occipital structures are salivary glands, making this pair anatomically incorrect for the nurse’s palpation assessment.

Choice D reason: The parotid glands, located anterior to the ears, and submandibular glands, below the mandible, are the two pairs of salivary glands accessible for palpation. Their anatomical positions allow external assessment, making this the correct choice.

A. “We need to determine the areas of tenderness before using percussion and palpation.” B. “Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination.” C. “Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation.” D. “Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation.” E. None F. None

Correct Answer is D

Explanation

Choice A reason: Tenderness is assessed by palpation, not auscultation, which focuses on sounds. Auscultation precedes to avoid altering bowel sounds, so this is incorrect for the reason given.

Choice B reason: Patient relaxation is beneficial but not the primary reason for auscultation first. Preventing bowel sound distortion by avoiding percussion and palpation is key, so this is incorrect.

Choice C reason: Vascular sounds like bruits are less affected by percussion/palpation than bowel sounds. Bowel sound distortion is the main concern, so this is incorrect for the primary reason.

Choice D reason: Auscultation before percussion and palpation prevents distortion of bowel sounds, which can be altered by manipulation. This is the correct reason, reflecting proper abdominal assessment technique.

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The nurse is caring for several patients on a pediatric unit. Which patient should the nurse be most concerned about possible abuse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When examining the face, the nurse is aware that which two pairs of salivary glands are accessible for palpation?

Correct Answer is D

Explanation

The nurse is watching a new graduate nurse perform auscultation of a patient’s abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

Correct Answer is D

Explanation

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