Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for four clients at an urgent care center. Which of the following clients should the nurse suspect has been physically abused?
A. 3-year-old toddler with scalding burns over the face and chest reportedly sustained when the child pulled on tablecloth, spilling a cup of tea on himself.
A) 3-year-old toddler with scalding burns over the face and chest reportedly sustained when the child pulled on a tablecloth, spilling a cup of tea on himself: Scalding burns in young children can be accidental, especially if the burns are consistent with typical patterns seen in such accidents. However, burns covering a large area, especially on the face and chest, may warrant further investigation to rule out abuse, particularly if the explanation seems inconsistent with the injury.
B. 6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle.
B) 6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle: A spiral fracture is often associated with a twisting or rotational force, which is less common in typical bicycle accidents. Spiral fractures in children can be indicative of physical abuse, particularly if the explanation for the injury does not fit the typical mechanisms of injury associated with the reported activity. This type of fracture should prompt a thorough evaluation for possible abuse.
C. 14-month-old toddler who is reportedly learning to walk and has several bruises on bony prominences of the lower legs and elbows.
C) 14-month-old toddler who is reportedly learning to walk and has several bruises on bony prominences of the lower legs and elbows: Bruises on bony prominences are common in toddlers who are learning to walk and are prone to minor falls. This pattern of bruising is usually consistent with typical developmental activities rather than abuse. However, repeated or severe bruising should still be evaluated carefully.
D. 9-month-old infant who sustained near drowning when he reportedly climbed into the tub and turned on the water.
D) 9-month-old infant who sustained near drowning when he reportedly climbed into the tub and turned on the water: While near drowning in an infant is a serious concern, it is less likely to be related to physical abuse if the explanation involves an accidental event. A thorough assessment is necessary to ensure safety and prevent further incidents, but the described scenario is not as indicative of abuse as a spiral fracture.
This question is an excerpt from Nurse Dive's nursing test bank - PNU Adult Health II Spring 2023 Proctored Exam 2. Take the full exam now
Full Explanation
Answer: B. 6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle.
Rationale:
A) 3-year-old toddler with scalding burns over the face and chest reportedly sustained when the child pulled on a tablecloth, spilling a cup of tea on himself:
Scalding burns in young children can be accidental, especially if the burns are consistent with typical patterns seen in such accidents. However, burns covering a large area, especially on the face and chest, may warrant further investigation to rule out abuse, particularly if the explanation seems inconsistent with the injury.
B) 6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle:
A spiral fracture is often associated with a twisting or rotational force, which is less common in typical bicycle accidents. Spiral fractures in children can be indicative of physical abuse, particularly if the explanation for the injury does not fit the typical mechanisms of injury associated with the reported activity. This type of fracture should prompt a thorough evaluation for possible abuse.
C) 14-month-old toddler who is reportedly learning to walk and has several bruises on bony prominences of the lower legs and elbows:
Bruises on bony prominences are common in toddlers who are learning to walk and are prone to minor falls. This pattern of bruising is usually consistent with typical developmental activities rather than abuse. However, repeated or severe bruising should still be evaluated carefully.
D) 9-month-old infant who sustained near drowning when he reportedly climbed into the tub and turned on the water:
While near drowning in an infant is a serious concern, it is less likely to be related to physical abuse if the explanation involves an accidental event. A thorough assessment is necessary to ensure safety and prevent further incidents, but the described scenario is not as indicative of abuse as a spiral fracture.
Similar Questions
A nurse is collecting data on a client who is experiencing chronic stress. Which of the following is an expected finding?
A. Hypotension
B. Increased cognitive awareness
C. Viral infection
Chronic stress can suppress the immune system, making it easier for viral infections to occur. Hypotension is not a common finding in chronic stress, as the body usually responds to stress by releasing adrenaline, which can increase blood pressure. Increased cognitive awareness and increased energy can occur in response to acute stress, but chronic stress can lead to mental and physical exhaustion.
D. Increased energy
Full Explanation
Chronic stress can suppress the immune system, making it easier for viral infections to occur. Hypotension is not a common finding in chronic stress, as the body usually responds to stress by releasing adrenaline, which can increase blood pressure. Increased cognitive awareness and increased energy can occur in response to acute stress, but chronic stress can lead to mental and physical exhaustion.
A nurse is caring for a client who has obsessive-compulsive disorder (OCD) and is constantly picking up after others and cleaning in the day room. The nurse should recognize the client's actions as which of the following?
A. Manipulating and controlling others' behavior.
B. Decreasing anxiety to a tolerable level.
In clients with obsessive-compulsive disorder (OCD), cleaning and organizing can be a way of decreasing anxiety to a tolerable level. This behavior is a compulsive behavior that is often related to the individual's obsessions. It is not an attempt to manipulate or control others, limit interaction with others, or focus attention on useful tasks.
C. Limiting the amount of time available for interaction with others.
D. Focusing attention on useful tasks.
Full Explanation
In clients with obsessive-compulsive disorder (OCD), cleaning and organizing can be a way of decreasing anxiety to a tolerable level. This behavior is a compulsive behavior that is often related to the individual's obsessions. It is not an attempt to manipulate or control others, limit interaction with others, or focus attention on useful tasks.
A patient without health insurance comes into the Emergency department limping and dripping blood from a head wound. Which of the following should be done first for this patient?
A. Determine triage level and examine and stabilize as needed.
The nurse should determine the patient's triage level and examine and stabilize the patient as needed when caring for a patient without health insurance who is limping and dripping blood from a head wound in the Emergency department. This intervention is the priority because the patient could be at risk of life-threatening complications if their condition is left untreated.
B. Give the patient information about facilities that specialize in treating people without health insurance.
C. Ask the patient to sign in and provide method of payment for services.
D. Transfer the patient to a hospital that specializes in traumatic brain injuries.
Full Explanation
The nurse should determine the patient's triage level and examine and stabilize the patient as needed when caring for a patient without health insurance who is limping and dripping blood from a head wound in the Emergency department. This intervention is the priority because the patient could be at risk of life-threatening complications if their condition is left untreated. Giving the patient information about facilities that specialize in treating people without health insurance, choice B, and asking the patient to sign in and provide method of payment for services, choice C, may be necessary but are not the priority at this time. Transferring the patient to a hospital that specializes in traumatic brain injuries, choice D, may be necessary after stabilizing the patient, but it is not the priority at this time.