Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse?
A. The child exhibits discomfort while walking
This is correct because discomfort while walking can indicate genital trauma or infection, which are possible signs of sexual abuse.
B. The child has thin extremities
This is incorrect because thin extremities can be caused by many factors, such as malnutrition, genetic disorders, or chronic diseases, that are not necessarily related to sexual abuse.
C. The child has bruises on the upper back
This is incorrect because bruises on the upper back can result from accidental injuries, such as falls or bumps, or from physical abuse, such as hitting or kicking, but not specifically from sexual abuse.
D. The child is wearing a stained shirt
This is incorrect because a stained shirt can be due to poor hygiene, food spills, or environmental factors, but not necessarily from sexual abuse.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
A - This is correct because discomfort while walking can indicate genital trauma or infection, which are possible signs of sexual abuse.
B - This is incorrect because thin extremities can be caused by many factors, such as malnutrition, genetic disorders, or chronic diseases, that are not necessarily related to sexual abuse.
C - This is incorrect because bruises on the upper back can result from accidental injuries, such as falls or bumps, or from physical abuse, such as hitting or kicking, but not specifically from sexual abuse.
D - This is incorrect because a stained shirt can be due to poor hygiene, food spills, or environmental factors, but not necessarily from sexual abuse.
Similar Questions
A nurse is caring for a client who is 1 day postoperative following a total thyroidectomy.
Complete the following sentence by using the lists of options.
The client is at the highest risk for developing hypocalcemia evidenced by the
Full Explanation
Total calcium 8.0 mg/dL (9.0 to 10.5 mg/dL) is correct.
A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect?
A. Weight gain
This is incorrect because weight gain is not expected in clients who have COPD, as they often have difficulty eating and digesting food due to dyspnea and fatigue.
B. Decrease in anteroposterior diameter of the chest
This is incorrect because a decrease in anteroposterior diameter of the chest is not typical of COPD, as the condition causes hyperinflation and air trapping in the lungs, leading to an increase in chest size and a barrel-shaped appearance.
C. HCO3 24 mEq/L
This is incorrect because HCO3 24 mEq/L is within the normal range for blood bicarbonate levels, which are 22 to 26 mEq/L. Clients who have COPD often have chronic respiratory acidosis, which stimulates the kidneys to retain bicarbonate and increase its levels in the blood to compensate for the low pH.
D. pH 7.31
This is correct because pH 7.31 indicates acidosis, which is common in clients who have COPD due to impaired gas exchange and accumulation of carbon dioxide in the blood.
Full Explanation
pH 7.31
Rationale:
A - This is incorrect because weight gain is not expected in clients who have COPD, as they often have difficulty eating and digesting food due to dyspnea and fatigue.
B - This is incorrect because a decrease in anteroposterior diameter of the chest is not typical of COPD, as the condition causes hyperinflation and air trapping in the lungs, leading to an increase in chest size and a barrel-shaped appearance.
C - This is incorrect because HCO3 24 mEq/L is within the normal range for blood bicarbonate levels, which are 22 to 26 mEq/L. Clients who have COPD often have chronic respiratory acidosis, which stimulates the kidneys to retain bicarbonate and increase its levels in the blood to compensate for the low pH.
D - This is correct because pH 7.31 indicates acidosis, which is common in clients who have COPD due to impaired gas exchange and accumulation of carbon dioxide in the blood.
A nurse is caring for a client who has acute blood loss following a trauma. The client refuses a blood transfusion that might potentially save their life. Which of the following actions should the nurse take first?
A. Document the client's refusal in the medical record
Documenting the client's refusal in the medical record is an important action, but not the first one. The nurse should first try to understand the client's perspective and address any concerns or misconceptions they might have about the blood transfusion. This choice is incorrect.
B. Honor the client's decision to refuse the blood transfusion
Honoring the client's decision to refuse the blood transfusion is a respectful and ethical action, but not the first one. The nurse should first attempt to educate and persuade the client about the benefits and risks of the treatment, and respect their autonomy only after ensuring that they have made an informed decision. This choice is incorrect.
C. Explore the client's reasons for refusing the treatment
Exploring the client's reasons for refusing the treatment is the first action that the nurse should take. The nurse should use effective communication skills to elicit the client's beliefs, values, fears, and preferences regarding the blood transfusion, and provide factual and evidencebased information to address any knowledge gaps or misconceptions. The nurse should also assess the client's decision-making capacity and determine if they are competent to refuse the treatment. This choice is correct.
D. Discuss the client's refusal with the provider
Discussing the client's refusal with the provider is an appropriate action, but not the first one. The nurse should first try to resolve the issue with the client directly, and involve the provider only if they are unable to do so or if there are legal or ethical implications that require further consultation. This choice is incorrect.
Full Explanation
Explore the client's reasons for refusing the treatment.
- A. Documenting the client's refusal in the medical record is an important action, but not the first one. The nurse should first try to understand the client's perspective and address any concerns or misconceptions they might have about the blood transfusion. This choice is incorrect.
- B. Honoring the client's decision to refuse the blood transfusion is a respectful and ethical action, but not the first one. The nurse should first attempt to educate and persuade the client about the benefits and risks of the treatment, and respect their autonomy only after ensuring that they have made an informed decision. This choice is incorrect.
- C. Exploring the client's reasons for refusing the treatment is the first action that the nurse should take. The nurse should use effective communication skills to elicit the client's beliefs, values, fears, and preferences regarding the blood transfusion, and provide factual and evidencebased information to address any knowledge gaps or misconceptions. The nurse should also assess the client's decision-making capacity and determine if they are competent to refuse the treatment. This choice is correct.
- D. Discussing the client's refusal with the provider is an appropriate action, but not the first one. The nurse should first try to resolve the issue with the client directly, and involve the provider only if they are unable to do so or if there are legal or ethical implications that require further consultation. This choice is incorrect.