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 C

Explanation

Choice A reason: Standing 6 feet away is too far for a whisper test, which is typically done at 1–2 feet. Whispering words for repetition is the standard method, so this is incorrect for hearing assessment.

Choice B reason: Occluding one ear tests unilateral hearing but isn’t the primary voice test method. Whispering random words and checking repetition directly assesses hearing, so this is not the best action.

Choice C reason: Whispering random numbers, words, or letters at 1–2 feet and asking the patient to repeat them is the standard voice test for hearing. This method is effective, making it the correct choice.

Choice D reason: Shielding lips muffles sound unnecessarily and prevents lip-reading, which isn’t the goal. Clear whispering and repetition test auditory function, so this is incorrect for the voice test.

A. Subjective report B. Patient’s vital signs C. Results of an x-ray D. Physical examination

Correct Answer is A

Explanation

Choice A reason: In a conscious, alert, and oriented patient, the subjective report is the most reliable pain indicator, as pain is a subjective experience. The patient’s description of intensity, location, and quality directly reflects their perception, guided by neurological pain pathways, making this the gold standard.

Choice B reason: Vital signs like elevated heart rate or blood pressure may suggest pain but are nonspecific, as they can result from anxiety, exertion, or other conditions. They are less reliable than the patient’s verbal report, which directly conveys the pain experience.

Choice C reason: X-ray results may identify structural issues but cannot directly assess pain, a subjective sensation processed by the brain’s pain pathways. They are diagnostic, not experiential, making them unreliable for gauging pain in a conscious patient.

Choice D reason: Physical examination findings, like guarding or grimacing, are indirect pain indicators and less reliable than the patient’s subjective report. These signs may be absent or misleading in some patients, making the verbal description more accurate for pain assessment.

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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

In performing a voice test to assess hearing, which of these actions would the nurse perform?

Correct Answer is C

Explanation

The nurse is assessing a patient’s pain. Which would be the most reliable indicator of pain in a conscious, alert, and oriented patient?

Correct Answer is A

Explanation

The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system?

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Which is the most important step that the nurse can take to prevent the transmission of microorganisms in the hospital?

A nurse in the emergency center is assessing the tonsils of a patient and observes that the tonsils are swollen to the point of touching. How should the nurse document this finding?

During an interview, the nurse states, “What brings you to the clinic today?” Which communication technique is used with this statement?

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

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. How should the nurse document this finding?