A nurse is caring for a 3-year-old child who has had 160 mL of urine output over the past 8-hour period.

The child weighs 33 lb.

Which of the following actions should the nurse take?

The correct answer is choiceb. Firmly attached white particles on the hair.

Choice A rationale:

Itching and scratching of the head are common symptoms of pediculosis capitis, but they are not definitive indicators. Itching can be caused by various other conditions such as dandruff or allergies.

Choice B rationale:

Firmly attached white particles on the hair, known as nits, are a definitive sign of pediculosis capitis.Nits are lice eggs that stick to the hair shafts and are difficult to remove.

Choice C rationale:

Thick yellow crusted lesions on a red base are more indicative of impetigo, a bacterial skin infection, rather than pediculosis capitis.

Choice D rationale:

Patchy areas of hair loss are typically associated with conditions like alopecia areata or fungal infections such as tinea capitis, not pediculosis capitis.

a.While involving mental health professionals can be part of a broader intervention plan, it is not the immediate priority in cases of suspected abuse. The nurse must first address the immediate safety concerns and follow the required reporting procedures.

b.Separating the child from the parents without proper authority or immediate threat can escalate the situation and may not be legally permissible. This action should be taken by authorities with the legal power to do so if deemed necessary.

c.Nurses are mandated reporters, which means they are legally required to report any suspected child abuse to the appropriate authorities immediately. This action ensures that the child’s safety is prioritized and that a proper investigation can be initiated however,obtaining a detailed history is the priority.

d.When a nurse observes several bruises on a child, the initial action should be toobtain a detailed history. This step allows the nurse to gather information about the circumstances surrounding the bruises, assess for any potential signs of abuse, and determine the most appropriate course of action.