A 2-month-old is brought into the emergency room. Which factor leads the RN to suspect abusive head trauma?
Sunken fontanels
Retinal hemorrhage
Laceration to forearm.
Large bruises on the body
The Correct Answer is B
A. Sunken fontanels: Sunken fontanels are typically associated with dehydration rather than abusive head trauma.
B. Retinal haemorrhage: Retinal haemorrhages are a key indicator of abusive head trauma, such as shaken baby syndrome. They are caused by the shearing forces of rapid acceleration and deceleration.
C. Laceration to forearm: While concerning, a laceration to the forearm is not specific to abusive head trauma and could result from various types of trauma.
D. Large bruises on the body: While large bruises might indicate physical abuse, they are not specific to head trauma and do not point as directly to abusive head trauma as retinal haemorrhages do.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "The most common manifestation of postpartum depression is harming the infant." This is incorrect; harming the infant is a severe complication but not the most common manifestation.
B. "It's common for clients who have postpartum depression to exhibit psychotic behavior." Psychotic behavior is a rare but serious complication of postpartum depression.
C. "Postpartum depression usually begins 48 hours after childbirth." Postpartum blues may start within this timeframe, but postpartum depression typically manifests later.
D. "Postpartum depression is more likely to occur in women who have a history of depression." This statement correctly identifies a significant risk factor for postpartum depression.
Correct Answer is B
Explanation
A. Hypoplastic heart syndrome: Characterized by underdevelopment of the left side of the heart, not mixing of blood.
B. Atrioventricular canal defect: An atrioventricular canal defect allows oxygenated and deoxygenated blood to mix due to the presence of a common atrioventricular valve and defects in the atrial and ventricular septa. This defect results in a mixture of oxygenated and deoxygenated blood, which can cause varying levels of oxygenation in the blood delivered to the body.
C. Tetralogy of Fallot: Involves a ventricular septal defect leading to right-to-left shunting, but not a direct mixing of oxygenated and deoxygenated blood.
D. Coarctation of the aorta: Involves narrowing of the aorta, not mixing of oxygenated and deoxygenated blood.
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