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NurseDive Free Nursing Practice Question
A nurse on a medical-surgical unit is caring for a group of children. Which of the following findings should alert the nurse that one of the children is a potential victim of abuse?
A. A preschooler who has a BMI indicating obesity
While childhood obesity is a health concern, it is not a specific indicator of abuse. Obesity can result from dietary habits, lack of physical activity, or medical conditions.
B. A school-age child who cries when the nurse is giving him an injection
Fear of injections is common in children and is a typical developmental response. Crying during an injection is not an indicator of abuse and is expected behavior for many children.
C. An adolescent who asks to stay in the hospital because he likes the room
While this finding alone does not confirm abuse, it may indicate an underlying issue in the adolescent's home environment. It requires further exploration through careful, open-ended questioning to assess for potential emotional or physical abuse or neglect.
D. A toddler who has multiple bruises on the shins of both legs and his parents report that he is clumsy
Bruising on the shins of toddlers is common due to normal play and falls during development. The explanation provided by the parents aligns with typical toddler behavior and does not raise immediate concerns for abuse unless the bruises are in unusual locations (e.g., abdomen, back, or thighs).
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Full Explanation
A. While childhood obesity is a health concern, it is not a specific indicator of abuse. Obesity can result from dietary habits, lack of physical activity, or medical conditions.
B. Fear of injections is common in children and is a typical developmental response. Crying during an injection is not an indicator of abuse and is expected behavior for many children.
C. While this finding alone does not confirm abuse, it may indicate an underlying issue in the adolescent's home environment. It requires further exploration through careful, open-ended questioning to assess for potential emotional or physical abuse or neglect.
D. Bruising on the shins of toddlers is common due to normal play and falls during development. The explanation provided by the parents aligns with typical toddler behavior and does not raise immediate concerns for abuse unless the bruises are in unusual locations (e.g., abdomen, back, or thighs).
Similar Questions
A nurse is caring for a client and using active listening skills. Which of the following actions should the nurse take?
A. Have a pen and paper.
Have a pen and paper.Having a pen and paper can be helpful during the conversation as it allows the nurse to jot down important points, keywords, or reminders. However, it's not directly related to active listening itself but can aid in retaining and recalling information.
B. Use intermittent eye contact.
Use intermittent eye contact.Intermittent eye contact is a crucial aspect of active listening. It shows that the nurse is engaged and attentive to the client's communication. However, it's essential to maintain a balance and avoid prolonged staring, which can be perceived as intimidating or intrusive.
C. Sit side-by-side with the client.
Sit side-by-side with the client.Sitting side-by-side with the client can create a sense of partnership and equality in the conversation. It can also help in establishing a comfortable and open environment for communication, which is beneficial for active listening.
D. Lean back in the chair.
Lean back in the chair.Leaning back in the chair can convey a relaxed and open posture, which can contribute to a positive communication atmosphere. However, it's crucial to maintain an attentive posture and avoid appearing disinterested or unengaged.
Full Explanation
Explanation:
A. Have a pen and paper.
Having a pen and paper can be helpful during the conversation as it allows the nurse to jot down important points, keywords, or reminders. However, it's not directly related to active listening itself but can aid in retaining and recalling information.
B. Use intermittent eye contact.
Intermittent eye contact is a crucial aspect of active listening. It shows that the nurse is engaged and attentive to the client's communication. However, it's essential to maintain a balance and avoid prolonged staring, which can be perceived as intimidating or intrusive.
C. Sit side-by-side with the client.
Sitting side-by-side with the client can create a sense of partnership and equality in the conversation. It can also help in establishing a comfortable and open environment for communication, which is beneficial for active listening.
D. Lean back in the chair.
Leaning back in the chair can convey a relaxed and open posture, which can contribute to a positive communication atmosphere. However, it's crucial to maintain an attentive posture and avoid appearing disinterested or unengaged.
A nurse is discussing the reporting of child abuse with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. "Reporting is voluntary for health care workers."
"Reporting is voluntary for health care workers."This statement is incorrect. Reporting child abuse is not voluntary for healthcare workers; it is a legal requirement in many jurisdictions. Failure to report suspected abuse can lead to legal and professional consequences.
B. "Civil liability can result if the abuse can't be proven."
"Civil liability can result if the abuse can't be proven."While civil liability may be a concern in some situations, it is not the primary reason for reporting child abuse. The main purpose of reporting is to ensure the safety and well-being of the child, not to prove abuse in a legal sense.
C. "Evidence of abuse must be collected prior to reporting."
"Evidence of abuse must be collected prior to reporting."This statement is incorrect. While collecting evidence can be important in legal proceedings, it is not the responsibility of healthcare workers to collect evidence of abuse before reporting. Suspected cases of abuse should be reported promptly to the appropriate authorities, who are responsible for investigating and gathering evidence.
D. "If suspicion of abuse exists then reporting is mandatory."
"If suspicion of abuse exists then reporting is mandatory."This statement correctly reflects the legal and ethical obligation of healthcare workers to report suspected cases of child abuse. Healthcare professionals are mandated reporters, which means they are required by law to report any suspicion of child abuse or neglect, even if there is no concrete evidence. Reporting is not voluntary for healthcare workers, and failure to report suspected abuse can result in serious consequences, including legal penalties and professional sanctions.
Full Explanation
Explanation:
A. "Reporting is voluntary for health care workers."
This statement is incorrect. Reporting child abuse is not voluntary for healthcare workers; it is a legal requirement in many jurisdictions. Failure to report suspected abuse can lead to legal and professional consequences.
B. "Civil liability can result if the abuse can't be proven."
While civil liability may be a concern in some situations, it is not the primary reason for reporting child abuse. The main purpose of reporting is to ensure the safety and well-being of the child, not to prove abuse in a legal sense.
C. "Evidence of abuse must be collected prior to reporting."
This statement is incorrect. While collecting evidence can be important in legal proceedings, it is not the responsibility of healthcare workers to collect evidence of abuse before reporting. Suspected cases of abuse should be reported promptly to the appropriate authorities, who are responsible for investigating and gathering evidence.
D. "If suspicion of abuse exists then reporting is mandatory."
This statement correctly reflects the legal and ethical obligation of healthcare workers to report suspected cases of child abuse. Healthcare professionals are mandated reporters, which means they are required by law to report any suspicion of child abuse or neglect, even if there is no concrete evidence. Reporting is not voluntary for healthcare workers, and failure to report suspected abuse can result in serious consequences, including legal penalties and professional sanctions.
A home health nurse is conducting a home-safety risk appraisal for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply.)
A. Bathtub with rails
Bathtub with rails:Having a bathtub with rails is generally considered a safety measure, as it can assist the client in safely entering and exiting the bathtub. Rails provide support and stability, especially for older adults who may have mobility issues. Therefore, this finding is not typically identified as a safety risk.
B. Raised toilet seats
Raised toilet seats:Raised toilet seats can also be beneficial for older adults with mobility challenges, as they make it easier to sit down and stand up from the toilet. Similar to bathtub rails, raised toilet seats are considered a safety measure rather than a safety risk.
C. Electric cords behind furniture
Electric cords behind furniture:Electric cords behind furniture pose a tripping hazard, especially for older adults who may have reduced balance or vision. Trips and falls can lead to serious injuries, so it's important to keep walkways clear of obstacles, including electric cords. Therefore, this finding is identified as a safety risk.
D. Water heater temperature 54.4°C (130° F)
Water heater temperature 54.4°C (130° F):The recommended safe water heater temperature to prevent scalding injuries is typically around 48.9°C (120°F). A water heater temperature of 54.4°C (130°F) is higher than the recommended safe range and can increase the risk of scalding injuries, especially for older adults with sensitive skin or reduced sensation. Therefore, this finding is identified as a safety risk.
E. Throw rugs
Throw rugs:Throw rugs are common tripping hazards, particularly if they are not secured to the floor or have curled edges. Older adults can easily trip on throw rugs, leading to falls and injuries. It's recommended to remove or secure throw rugs to reduce the risk of falls, making this finding a safety risk.
Full Explanation
Explanation:
A. Bathtub with rails:
Having a bathtub with rails is generally considered a safety measure, as it can assist the client in safely entering and exiting the bathtub. Rails provide support and stability, especially for older adults who may have mobility issues. Therefore, this finding is not typically identified as a safety risk.
B. Raised toilet seats:
Raised toilet seats can also be beneficial for older adults with mobility challenges, as they make it easier to sit down and stand up from the toilet. Similar to bathtub rails, raised toilet seats are considered a safety measure rather than a safety risk.
C. Electric cords behind furniture:
Electric cords behind furniture pose a tripping hazard, especially for older adults who may have reduced balance or vision. Trips and falls can lead to serious injuries, so it's important to keep walkways clear of obstacles, including electric cords. Therefore, this finding is identified as a safety risk.
D. Water heater temperature 54.4°C (130° F):
The recommended safe water heater temperature to prevent scalding injuries is typically around 48.9°C (120°F). A water heater temperature of 54.4°C (130°F) is higher than the recommended safe range and can increase the risk of scalding injuries, especially for older adults with sensitive skin or reduced sensation. Therefore, this finding is identified as a safety risk.
E. Throw rugs:
Throw rugs are common tripping hazards, particularly if they are not secured to the floor or have curled edges. Older adults can easily trip on throw rugs, leading to falls and injuries. It's recommended to remove or secure throw rugs to reduce the risk of falls, making this finding a safety risk.