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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Ensuring that the client takes care of their ADLS to prevent dependence: While promoting independence is important, ensuring safety is a higher priority to prevent immediate harm.
B. Ensuring that the client environment is safe to prevent injury: Safety is the top priority for clients with Alzheimer's due to their increased risk of falls, wandering, and other accidents. A safe environment helps prevent injuries.
C. Ensuring that the client receives food they like to prevent anxiety: Although providing familiar and preferred foods can reduce anxiety, it is not as critical as ensuring a safe environment.
D. Ensuring that the client meets the other patients to prevent social isolation: Social interaction is beneficial, but ensuring safety takes precedence to prevent potential harm.

A. Handwashing B. Gardasil injection C. Penicillin D. Use of barrier protection E. Perineal care of genital lesions

Correct Answer is ["A","D","E"]

Explanation

A. Handwashing. Good hygiene is important to prevent the spread of the virus, especially after touching the lesions.
B. Gardasil injection. Gardasil is a vaccine for HPV, not HSV. It is not relevant for the management of herpes.
C. Penicillin. Penicillin is not effective against viral infections like herpes; antiviral medications such as acyclovir are used for treatment.
D. Use of barrier protection. Barrier methods such as condoms are crucial in reducing the risk of transmission of HSV-2 to sexual partners.
E. Perineal care of genital lesions. Proper care of lesions can help reduce discomfort and prevent secondary infections.

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A 2-month-old is brought into the emergency room. Which factor leads the RN to suspect abusive head trauma?

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Naxlex Comprehensive Predictor Exams

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A 19-year-old goes to Planned Parenthood clinic with complaints of painful lesions, fever, headache, and vaginal discharge. After testing she is diagnosed with Herpes simplex virus type 2. What education should the nurse include in a teaching plan? (Select All that Apply.)

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