When obtaining a history from parents of a 4-year-old child, what indicator should prompt the nurse to consider suspected child abuse?
Consistent growth pattern on the 25th percentile
A contusion on the child's leg
Fearful behavior when the nurse enters the room
Inconsistent story on the child's injury.
The Correct Answer is D
Choice A reason: A consistent growth pattern on the 25th percentile is not an indicator of child abuse. It means that the child is growing normally and is within the expected range for their age and gender.
Choice B reason: A contusion on the child's leg is not necessarily an indicator of child abuse. It could be a result of accidental injury or normal play. However, the nurse should assess the location, size, shape, and color of the bruise, and compare it with the parents' explanation.
Choice C reason: Fearful behavior when the nurse enters the room is not a specific indicator of child abuse. It could be a sign of anxiety, shyness, or discomfort in an unfamiliar setting. The nurse should try to establish rapport with the child and use developmentally appropriate communication techniques.
Choice D reason: An inconsistent story on the child's injury is a strong indicator of child abuse. It suggests that the parents are trying to hide or cover up the cause of the injury, or that they are not aware of how the injury occurred. The nurse should document the discrepancies and report any suspicions of abuse to the appropriate authorities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not appropriate because it implies that the child's current diet is inadequate or incompatible with diabetes management. It may also offend the parents and the child by disregarding their cultural and religious preferences.
Choice B reason: This is appropriate because it shows respect and sensitivity for the child's and the parents' dietary choices. It also helps the nurse to tailor the dietary education and advice according to the child's needs and preferences.
Choice C reason: This is not appropriate because it contradicts the child's and the parents' beliefs and practices. Hindus consider fruit to be sacred and offer it to their gods. They do not eat fruit after it has been offered, as it is considered prasad, or blessed food.
Choice D reason: This is not appropriate because it assumes that meat is the only or the best source of protein. It may also violate the child's and the parents' ethical or religious values, as some Hindus avoid meat or certain types of meat.
Correct Answer is D
Explanation
Choice A reason: Calling the physician is not the first action because it would delay the immediate intervention of oxygen administration, which is critical for a patient with hypoxia. The physician should be notified after initiating oxygen therapy and assessing the patient's condition.
Choice B reason: Placing the patient on 10 L/min oxygen per nasal cannula is not the first action because it is too high of a flow rate for a two-year-old patient, and it could cause oxygen toxicity or barotrauma. The appropriate oxygen delivery device and flow rate should be determined based on the patient's age, weight, and clinical status.
Choice C reason: Assessing the patient is not the first action because it would also delay the immediate intervention of oxygen administration. The patient's pulse oximetry reading indicates severe hypoxia, which requires prompt treatment to prevent organ damage or death. The patient should be assessed after initiating oxygen therapy and monitoring vital signs.
Choice D reason: Administering oxygen and monitoring vital signs while calling the physician is the correct answer because it provides the most effective and timely response to the patient's hypoxia. Oxygen administration improves the patient's oxygen saturation and tissue perfusion, while vital sign monitoring helps to evaluate the patient's response to therapy and identify any complications. Calling the physician informs them of the situation and allows them to order further interventions or tests as needed.
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