Which observation made by an emergency department nurse would raise the suspicion that a 3-year-old child has been maltreated?
a. The parents are extremely calm in the emergency department.
b. The injury is unusual for a child of that age.
c. The child does not remember how he got hurt.
d. The child was doing something unsafe when the injury occurred.
B
An injury that is rarely found in children or is inconsistent with the age and condition of the child should raise suspicion of child maltreatment. The nurse should observe the parents' reaction to the child but must keep in mind that people behave very differently depending on culture, ethnicity, experience, and psychological makeup. The child may not remember what happened as a result of the injury itself, for example, sustaining a concussion. Also, a 3-year-old child may not be a reliable historian. The fact that the child was not supervised might be an area for health teaching. The nurse would need to gather more information to determine whether the parents have been negligent in the care of their child.
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The nurse is teaching a group of nursing students about adherence to medication in older adults. Which statement by the student indicates understanding of the teaching?
a. "An inability to pay for medications con-tributes to most intentional nonadherence among older adults." b. "Most issues associated with nonadhe-rence among older adults would be re-solved with simplified drug regimens." c. "Most nonadherence in older adults results in drug toxicity and adverse drug effects." d. "The majority of older patients who do not adhere to drug regimens do so inten-tionally."
The nurse is assessing heart sounds on a school-age child. Which should the nurse document as abnormal findings if found on the assessment? (Select all that apply.)
a. S4 heart sound b. S3 heart sound c. Grade II murmur d. S1 louder at the apex of the heart e. S2 louder than S1 in the aortic area
The nursing student tells her instructor, "My patient is Jewish and when I tried to teach her about her antihypertensive medication she said, ‘I'd rather eat chicken soup than take those medications
'" What is the most appropriate response by the instructor? a. "This is common folk medicine among some Jewish people. You can talk to her about taking her medications and eating chicken soup." b. "There is no scientific evidence to support chicken soup as a substitute for antihypertensive medications. Maybe you should do some research on this." c. "The patient can make her own choices and decisions, and there is nothing we can do about this." d. "You can tell the patient she can eat her soup, but she needs to understand that she has to take her medications first."
A nurse tests a reflex on 9-month-old infant's right foot by stroking the surface of the infant's foot, moving from the sole laterally up and across to the great toe. The expected response is:
a. Flexion of the right toes. b. Extension of the right ankle. c. Dorsiflexion of the right foot. d. Fanning of the toes of the right foot.