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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: To calculate the dose, divide the ordered 180 mg by the concentration of 250 mg per 5 ml: (180 mg ÷ 250 mg) × 5 ml = 0.72 × 5 = 3.6 ml. This precise calculation ensures the correct amount of Dilantin is administered, matching the provider’s order.
Choice B reason: A 4.5 ml dose would deliver 225 mg (4.5 ml × 250 mg/5 ml), exceeding the ordered 180 mg. This overdose could increase the risk of toxicity, as Dilantin has a narrow therapeutic range, making this an incorrect choice.
Choice C reason: A 5 ml dose delivers 250 mg (5 ml × 250 mg/5 ml), significantly more than the ordered 180 mg. This excessive dose could lead to adverse effects like ataxia or nystagmus, rendering this choice incorrect for the prescribed amount.
Choice D reason: A 7 ml dose would provide 350 mg (7 ml × 250 mg/5 ml), far exceeding the ordered 180 mg. Such a high dose could cause severe toxicity, including neurological symptoms, making this an inappropriate and unsafe choice.
Correct Answer is C
Explanation
Choice A reason: Asking about the last mammography focuses on screening, not the technique or frequency of self-examination. Inquiring about self-exam frequency ensures the patient performs it regularly, so this is incorrect for ensuring proper practice.
Choice B reason: Annual breast exams are clinical, but this question doesn’t confirm the patient patient performs self-exams. Asking about self-examination frequency directly addresses the practice, so this is not the best statement.
Choice C reason: Asking how often the patient performs breast self-examination confirms whether they do it regularly (e.g., monthly) and opens discussion on technique, ensuring correct practice. This is the best statement, so it’s correct.
Choice D reason: Physician visits are unrelated to self-performing self-examination at home. Frequency of breast self-exams is key to ensuring compliance, so this is incorrect for the nurse’s goal.
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