NCLEX Exam Practice Question of the Week - 04/27/11

Elsevier NCLEX Exam Review

Question: A nurse is assessing the family dynamics of a suspected abusive family. What behavior is expected? Select all that apply.

1. Child cringes when approached
2. Child has unexplained healed injuries
3. Parents are overly affectionate toward the child
4. Child lies still while surveying the environment
5. Parents give detailed accounts of the child's injuries

Answer: 1, 2, 4

Rationale: The child cringes when approached because past experiences with adults have inflicted pain rather than comfort. Evidence of past injuries may exist but the parents do not discuss them because this would be an admission of child abuse. Abused children are always on the alert for potential future abuse. Lying motionless prevents bringing attention to them; also, in the past resisting abuse often precipitated more abuse. Abusive parents are unable to provide any emotional support. Because abusing parents try to hide the fact of abuse, explanations about injuries usually are fabricated, inconsistent, and vague.

Clinical Area: Child Health Nursing
Client Need: Psychosocial Integrity
Cognitive Level: Analysis
Nursing Process: Assessment

This week’s NCLEX exam practice question can be found in:
Nugent: Mosby's Review Questions for the NCLEX-RN Exam, 7th edition, Chapter 5, pg 406, Question 81

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