A 2-month-old infant is brought to the emergency room.
Which factor should lead the RN to suspect that the child may have experienced abusive head trauma?
Sunken fontanels.
Retinal hemorrhage.
Large bruises on the body.
Laceration to the forearm.
The Correct Answer is B
Choice A rationale
Sunken fontanels are typically a sign of dehydration due to reduced intracranial pressure and are not specific to abusive head trauma. Abusive head trauma often results in elevated intracranial pressure or swelling, which would present differently. Therefore, this finding is unrelated to the mechanisms of abusive head trauma in a 2-month-old.
Choice B rationale
Retinal hemorrhages are strongly associated with abusive head trauma due to the shearing forces during shaking or impact, which rupture retinal blood vessels. This finding is a hallmark of non-accidental trauma in infants, as accidental injuries rarely cause this degree of internal ocular damage.
Choice C rationale
Large bruises on the body could indicate trauma but are not specific to abusive head trauma. Additionally, the pattern or location of bruises is significant for abuse, especially in non-mobile infants. However, bruises alone do not confirm head trauma specifically.
Choice D rationale
Lacerations, such as those on the forearm, might suggest trauma but lack specificity for abusive head trauma. Such injuries are more commonly associated with accidents or other forms of physical abuse that do not necessarily involve the head.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Pain is a hallmark symptom of sickle cell crisis due to vaso-occlusion, which restricts blood flow and oxygen delivery to tissues. It results from ischemia in affected areas, triggering severe discomfort that requires prompt management with analgesics and interventions to improve circulation.
Choice B rationale
Constipation is not typically associated with sickle cell crisis. While dehydration might contribute to gastrointestinal changes, the primary symptoms revolve around pain and vaso-occlusive events impacting blood flow and oxygen delivery.
Choice C rationale
High fever can occur due to infections secondary to spleen dysfunction in sickle cell patients, but it is not a direct symptom of crisis itself. Fever requires evaluation to rule out underlying causes, as infections pose serious risks for these individuals.
Choice D rationale
Bradycardia is atypical in sickle cell crisis. Instead, tachycardia may occur due to compensatory mechanisms for ischemia and hypoxia. Bradycardia is unrelated to the vaso-occlusive events characteristic of sickle cell crises. .
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
A large bruise on the forehead of a 2-year-old could occur from accidental falls, which are common at this developmental stage due to increased mobility and decreased coordination. It does not necessarily suggest abuse unless accompanied by other suspicious findings.
Choice B rationale
Circular abrasions around the wrists are highly indicative of physical abuse as they suggest binding injuries. Restraining a child is neither acceptable nor normal, and such findings must be reported for further investigation by child protective services.
Choice C rationale
A burn on the palm of a 10-year-old’s hand raises concerns for abuse as accidental burns usually occur on accessible areas like arms or legs, not the palm. This pattern could indicate intentional infliction, requiring mandatory reporting to authorities.
Choice D rationale
Splash burns on the front torso in a 6-year-old are suspicious if inconsistent with the child’s developmental abilities or history provided by caregivers. Intentional scald burns often follow specific patterns, like splash marks, and must be reported for investigation.
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