Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a child and notes several bruises. Which of the following actions should the nurse take?
A. Ask a psychiatrist to talk with the parents.
While involving mental health professionals can be part of a broader intervention plan, it is not the immediate priority in cases of suspected abuse. The nurse must first address the immediate safety concerns and follow the required reporting procedures.
B. Separate the child from the parents.
Separating the child from the parents without proper authority or immediate threat can escalate the situation and may not be legally permissible. This action should be taken by authorities with the legal power to do so if deemed necessary.
C. Report the suspected abuse to the authorities.
Nurses are mandated reporters, which means they are legally required to report any suspected child abuse to the appropriate authorities immediately. This action ensures that the child’s safety is prioritized and that a proper investigation can be initiated however, obtaining a detailed history is the priority.
D. Obtain a detailed history.
When a nurse observes several bruises on a child, the initial action should be to obtain a detailed history. This step allows the nurse to gather information about the circumstances surrounding the bruises, assess for any potential signs of abuse, and determine the most appropriate course of action.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom SP23 N23 N240 Proctored Exam 3 Ch 11 24 32 43 44. Take the full exam now
Full Explanation
a. While involving mental health professionals can be part of a broader intervention plan, it is not the immediate priority in cases of suspected abuse. The nurse must first address the immediate safety concerns and follow the required reporting procedures.
b. Separating the child from the parents without proper authority or immediate threat can escalate the situation and may not be legally permissible. This action should be taken by authorities with the legal power to do so if deemed necessary.
c. Nurses are mandated reporters, which means they are legally required to report any suspected child abuse to the appropriate authorities immediately. This action ensures that the child’s safety is prioritized and that a proper investigation can be initiated however, obtaining a detailed history is the priority.
d. When a nurse observes several bruises on a child, the initial action should be to obtain a detailed history. This step allows the nurse to gather information about the circumstances surrounding the bruises, assess for any potential signs of abuse, and determine the most appropriate course of action.
Similar Questions
A nurse is caring for an infant in a provider's office.
Medical History Provider Visit #1. Heart rate 144/min.
Axillary temperature 39.7° C (103.5°F). Respiratory rate 32/min.
Oxygen saturation 95% on room air. Provider Visit #2 (4 days later).
Axillary temperature 37.4° C (99.3° F). Heart rate 132/min.
Respiratory rate 28/min.
Oxygen saturation 97% on room air.
Which of the following actions should the nurse plan to take? Select the actions the nurse should plan to take.
A. Teach caregivers to change diapers when wet.
Frequent diaper changes are a standard practice to prevent diaper rash and skin irritation, which is particularly important in infants, regardless of the presence of diarrhea or other symptoms. Wet diapers can cause skin breakdown, especially in the context of illness, where skin may be more vulnerable. This is a proactive, preventive measure that aligns with general infant care.
B. Have caregivers administer 16 oz of water after each diarrhea stool.
The medical history does not mention diarrhea, so this action assumes a condition not supported by the data. Administering 16 oz of water per diarrhea stool is excessive for an infant, as it could lead to fluid overload or electrolyte imbalances. Infants typically require smaller, calculated fluid volumes (e.g., oral rehydration solutions) based on weight and clinical status if diarrhea is present. Without evidence of diarrhea, this action is not indicated.
C. Cleanse the diaper area with soap and water.
Cleansing the diaper area with mild soap and water is a standard nursing intervention to maintain skin integrity. It removes irritants and bacteria effectively, reducing the risk of developing a secondary diaper dermatitis.
D. Collect nasal drainage for culture and sensitivity.
Only done if ordered and if infection is suspected. At follow-up (Visit #2), infant is afebrile and stable—no need for culture.
F. Teach caregivers to apply talcum powder to creases.
Talcum powder is not recommended for infants due to the risk of inhalation, which can cause respiratory issues, especially in an infant with a recent respiratory illness. Modern pediatric guidelines favor keeping skin dry and using barrier creams (e.g., zinc oxide) if needed, rather than talcum powder, to prevent irritation in skin creases.
G. Use a nasal aspirator after feedings.
Using a nasal aspirator should be done before feedings, not after. Suctioning after a feeding can trigger the gag reflex and cause the infant to vomit, increasing the risk of aspiration.
Full Explanation
Choice A rationale: Teaching caregivers to change diapers immediately when wet is essential for preventing skin breakdown and secondary infections, especially when an infant has been experiencing high fevers or potential gastrointestinal distress.
Choice B rationale: Administering 16 oz of water to an infant after each stool is dangerous. Infants are at high risk for water intoxication and electrolyte imbalances; rehydration should involve breast milk, formula, or oral rehydration solutions.
Choice C rationale: Cleansing the diaper area with mild soap and water is a standard nursing intervention to maintain skin integrity. It removes irritants and bacteria effectively, reducing the risk of developing a secondary diaper dermatitis.
Choice D rationale: Collecting nasal drainage for culture is not indicated based on the provided vital signs. The infant's temperature has improved, and there is no specific evidence of a worsening respiratory infection requiring a culture.
Choice F rationale: Caregivers should never apply talcum powder to an infant’s skin creases. Talcum powder poses a significant aspiration risk and can lead to severe respiratory distress or chronic lung irritation if inhaled.
Choice G rationale: Using a nasal aspirator should be done before feedings, not after. Suctioning after a feeding can trigger the gag reflex and cause the infant to vomit, increasing the risk of aspiration.
A nurse is caring for an infant in a provider's office. Medical History Diagnosis: Nurse's Notes Upper respiratory infection Provider prescriptions: Vital Signs • Amoxicillin and clavulanate suspension 225 mg PO twice daily for 10 days Ibuprofen liquid 50 mg PO every 6 to 8 hr, maximum 4 times daily, to treat fever Which of the following actions should the nurse take next to provide appropriate care for the infant?
A. Administer the Amoxicillin and clavulanate suspension immediately
Choice A is not an answer because the nurse should verify the dosage and frequency with the provider before administering any medication.
B. Administer the Ibuprofen liquid immediately
Choice B is not an answer because the nurse should verify the dosage and frequency with the provider before administering any medication.
C. Wait and monitor the infant's symptoms before administering any medication
Choice C is not an answer because waiting and monitoring the infant’s symptoms does not address the need to verify the dosage and frequency of medication administration with the provider.
D. Contact the provider to clarify the dosage and frequency of medication administration
Contact the provider to clarify the dosage and frequency of medication administration. The nurse should always verify the dosage and frequency of medication administration with the provider before administering any medication to ensure the safety and well-being of the infant.
Full Explanation
Contact the provider to clarify the dosage and frequency of medication administration.
The nurse should always verify the dosage and frequency of medication administration with the provider before administering any medication to ensure the safety and well-being of the infant.
Choice A is not an answer because the nurse should verify the dosage and frequency with the provider before administering any medication.
Choice B is not an answer because the nurse should verify the dosage and frequency with the provider before administering any medication.
Choice C is not an answer because waiting and monitoring the infant’s symptoms does not address the need to verify the dosage and frequency of medication administration with the provider.
A nurse is caring for a school-age child who has acute glomerulonephritis with peripheral edema and is producing 35 mL of urine per hour.
The nurse should place the client on which of the following diets?
A. Low-sodium, fluid-restricted.
The nurse should place the client on a low-sodium, fluid-restricted diet. Acute glomerulonephritis is a kidney disease that can cause fluid retention and edema. A low-sodium diet can help reduce fluid retention and swelling. Fluid restriction can also help manage fluid balance and prevent further complications.
B. Regular diet, no added salt.
Choice B is not the best answer because a regular diet with no added salt may still contain high levels of sodium.
C. Low-protein, low-potassium diet.
Choice C is not the best answer because a low-protein, low-potassium diet may not address the client’s fluid retention and edema.
D. Low-carbohydrate, low-protein diet.
Choice D is not the best answer because a low-carbohydrate, low-protein diet may not provide adequate nutrition for the client.
Full Explanation
The nurse should place the client on a low-sodium, fluid-restricted diet.
Acute glomerulonephritis is a kidney disease that can cause fluid retention and edema.
A low-sodium diet can help reduce fluid retention and swelling.
Fluid restriction can also help manage fluid balance and prevent further complications.
Choice B is not the best answer because a regular diet with no added salt may still contain high levels of sodium.
Choice C is not the best answer because a low-protein, low-potassium diet may not address the client’s fluid retention and edema.
Choice D is not the best answer because a low-carbohydrate, low-protein diet may not provide adequate nutrition for the client.