A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse?

- A. This client is at risk of harming themselves by removing the IV line, which could cause bleeding, infection, or loss of medication. This is a priority issue that requires immediate intervention by the nurse.

- B. This client is experiencing a common side effect of pain medication, which can be managed by administering antiemetics, fluids, or changing the medication. This is not a life-threatening issue and can be addressed after attending to the client in choice A.

- C. This client has a chronic condition that requires regular dialysis, but they are not in acute distress at this time. They should be monitored for signs of fluid overload, electrolyte imbalance, or infection, but they are not a priority over the client in choice A.

- D. This client has a psychosocial need that should be respected and supported by the nurse, but it is not an urgent issue that requires immediate attention. The nurse can arrange for a visit from the chaplain after attending to the client in choice A.

• A is incorrect because diarrhea is not an adverse effect of clonidine, but rather a symptom of other conditions such as infection, inflammation, or food intolerance.
• B is correct because dry mouth is a common adverse effect of clonidine, which is an alpha-2 adrenergic agonist that reduces sympathetic nervous system activity.
• C is incorrect because photophobia, or sensitivity to light, is not an adverse effect of clonidine, but rather a symptom of other conditions such as migraine, eye injury, or infection.
• D is incorrect because bruising, or bleeding under the skin, is not an adverse effect of clonidine, but rather a symptom of other conditions such as coagulation disorders, vitamin deficiency, or trauma.