A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?

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.

The correct answer is Choice A.

Choice A rationale: The initial step in assessing unexplained bruising in a toddler is to gather information directly from the caregivers. This establishes a clinical baseline and allows the nurse to evaluate consistency, plausibility, and emotional responses. Bruising in toddlers can be developmental due to increased mobility, but patterns, location, and frequency matter. Normal platelet count ranges from 150,000 to 450,000/mm³; abnormal bruising may suggest thrombocytopenia, coagulopathy, or trauma. Early dialogue supports accurate documentation and escalation if needed.

Choice B rationale: While engaging the toddler may seem appropriate, their developmental stage limits reliable verbal communication. Toddlers typically lack the cognitive and linguistic capacity to describe events accurately, especially those involving trauma or abuse. Their responses may be influenced by fear, confusion, or limited vocabulary. Relying on their account prematurely risks misinterpretation and emotional distress. Assessment should prioritize adult sources first, followed by observational and clinical data to guide further action.

Choice C rationale: Notifying social services is a critical step in suspected abuse but must follow preliminary assessment and documentation. Premature reporting without context may lead to unnecessary distress for the family and compromise the integrity of the investigation. The nurse must first gather objective findings, caregiver explanations, and clinical indicators. Social services involvement is warranted when findings suggest non-accidental trauma, inconsistent histories, or high-risk environments. The decision must be evidence-informed and procedurally sound.

Choice D rationale: Notifying the provider is essential for collaborative care but should follow initial data collection. The provider relies on the nurse’s observations and caregiver input to determine next steps, including diagnostic testing or referral. Immediate escalation without context may delay appropriate triage or misdirect resources. The nurse’s role includes thorough documentation, pattern recognition, and initiating dialogue with caregivers to inform the provider’s clinical judgment. This ensures a coordinated, evidence-based response.