A nurse in an urgent care clinic is collecting data from a group of clients. Which of the following findings should alert the nurse to the possibility of child maltreatment?
A 6-year-old child who is toilet trained and bedwetting
An 8-month-old infant who has stranger anxiety
An 18-month-old child who has several bruises on their shins
A 2-year-old child who kicks and screams when their parent leaves
The Correct Answer is A
A. Bedwetting in a toilet-trained child can be a sign of emotional distress or trauma, which may indicate maltreatment and should be further investigated.
B. Stranger anxiety is a normal developmental stage for an 8-month-old infant and does not suggest maltreatment.
C. Bruises on the shins of an 18-month-old child are common due to normal toddler activity and do not necessarily indicate maltreatment.
D. Separation anxiety, including kicking and screaming when a parent leaves, is typical behavior for a 2-year-old child and does not suggest maltreatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
Continuous pulse oximetry: Anticipated because the infant has respiratory distress and requires continuous monitoring of oxygen saturation.
Chest x-ray: Anticipated to assess the extent of lung involvement due to the respiratory distress and wheezing noted.
Peripheral IV line: Anticipated since the peripheral line will be used to administer intravenous medications and fluids.
Supine position: Contraindicated because the infant prefers to sit upright and shows signs of respiratory distress, such as nasal flaring and retractions.
Small, frequent feedings: Anticipated to ensure adequate nutrition despite feeding difficulties.
Monitor intake and output: Anticipated to assess hydration status, especially since the infant has had decreased intake and output.
Correct Answer is D
Explanation
A. Fruity breath odor is associated with hyperglycemia and ketoacidosis, not hypoglycemia.
B. Flushed skin is not a typical symptom of hypoglycemia.
C. Thirst is commonly associated with hyperglycemia.
D. Headache is a common symptom of hypoglycemia due to the lack of glucose supply to the brain.
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