QUESTIONS

1

The nurse should be aware of signs of physical, sexual, and emotional abuse and comply with state or provincial mandatory

reporting. Signs of abuse may include:

• Shaken baby syndrome (ie, irritability or lethargy, poor feeding, emesis, seizures)

• Burnsin the shape of household items (eg, iron, spatula), from cigarettes, or from immersion in scalding liquid

• Repeated injuries in varied stages of healing (eg, bruises, burns, fractures) (Option 4)

• Injuries to genitalia

• Lapsed time between the injury and the time when care is sought

• Inconsistency between the injury and the caregiver's explanation of the injury (eg, client's developmental

age,mechanism of injury)

(Options 1, 2, and 3) Toddlers and young children are prone to many accidental injuries (eg, aspiration or poisoning

fromforeign objects in the mouth, climbs onto and falls from furniture, pulling of objects from the table). The injuries

and caregivers' explanations are reasonable for these clients. Prior to discharge, the nurse should instruct caregivers on

child safety measures within the home to prevent future injury.

Educational objective:

The nurse should be aware of signs of physical, sexual, and emotional abuse, including repeated injuries in varied stages

of healing, shaken baby syndrome, and injuries to genitalia. Suspicion of abuse necessitates mandatory reporting

according tostate or provincial laws.

Paranoia is the belief that others desire or are attempting to persecute or harm (eg, spy on, cheat, follow, poison) the

individual. Clients with paranoid delusions often are suspicious of other people, including health care professionals, and

mayrefuse treatment or aid out of fear of being harmed.

Management of paranoia focuses on building trust with and grounding the client in reality. When the client believes food

has been poisoned, the nurse can build trust and promote adequate nutrition by offering unopened, individually

packaged food (Option 4).

Educational objective:

Nurses caring for clients who have paranoid delusions must work to build a trusting relationship and ground the client

while ensuring basic needs are met (eg, nutritional intake). When clients believe food is poisoned, the nurse should offer

unopened,individually packaged food to promote adequate intake without reinforcing delusions.

Steps for indwelling urinary catheter insertion for the male client include:

• Perform hand hygiene and open sterile catheterization kit (Option 3).