A nurse is reviewing the medical record of a school-age child who was admitted for suspected physical maltreatment. Which of the following findings in the child's medical history should the nurse identify as a potential risk factor for physical maltreatment?
Acute otitis media.
Myopia.
Prematurity.
Adopted.
The Correct Answer is D
Choice A rationale:
Acute otitis media is not a risk factor for physical maltreatment. It's an ear infection and does not directly contribute to the risk of physical abuse. The child's medical history should be assessed for factors that are more closely related to abuse.
Choice B rationale:
Myopia, or nearsightedness, is also not a risk factor for physical maltreatment. Myopia is a visual impairment and is not related to the risk of abuse. The nurse should focus on identifying factors that might indicate an increased likelihood of abuse.
Choice C rationale:
Prematurity can be a risk factor for various health issues in a child, but it is not directly linked to physical maltreatment. While preterm infants might have unique medical needs, being born prematurely does not inherently increase the risk of physical abuse.
Choice D rationale:
Correct Answer. Being adopted can be considered a potential risk factor for physical maltreatment. Children who are adopted might face certain challenges related to attachment, identity, and adjustment. It's important for healthcare providers to be vigilant and assess the child's situation comprehensively to ensure their safety and well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Hematocrit 36%. A hematocrit level of 36% falls within the normal range for adolescents. Hematocrit measures the proportion of blood volume occupied by red blood cells and is used to assess for anemia or polycythemia. A level of 36% is not a cause for concern in this case.
Choice B rationale:
Hemoglobin 12 g/dL. A hemoglobin level of 12 g/dL is within the normal range for adolescents. Hemoglobin is a protein in red blood cells that carries oxygen. This level indicates that the adolescent is not significantly anemic.
Choice C rationale:
Glucose 120 mg/dL. A glucose level of 120 mg/dL is within the normal range for a random blood glucose test. However, in the context of diabetes mellitus, the nurse should be more concerned about the HbA1c level, which reflects the average blood glucose level over the past few months.
Choice D rationale:
HbA1c 10.7%. HbA1c, or glycated hemoglobin, reflects the average blood glucose concentration over a span of approximately 2 to 3 months. An HbA1c level of 10.7% is significantly elevated and indicates poor long-term glucose control. This value suggests that the adolescent's diabetes management has not been effective, which can lead to an increased risk of diabetes-related complications over time. The nurse should notify the healthcare provider so that appropriate adjustments can be made to the treatment plan.
Correct Answer is A
Explanation
Choice A rationale:
Administer two puffs of albuterol. This is the correct answer because albuterol is a bronchodilator that helps to relieve acute asthma symptoms by opening up the airways. In a child experiencing difficulty breathing due to asthma, prompt administration of albuterol can help alleviate the symptoms and improve breathing.
Choice B rationale:
Place the child in the supine position. Placing the child in the supine position can further compromise their breathing, especially in a situation of asthma exacerbation. This position can restrict the airways and make breathing more difficult, so it is not an appropriate action.
Choice C rationale:
Encourage the use of a flutter mucus clearance device. While mucus clearance devices can be helpful for individuals with chronic respiratory conditions, such as cystic fibrosis, it is not the priority action for a child experiencing acute asthma symptoms. The immediate focus should be on relieving the airway constriction and addressing the breathing difficulty.
Choice D rationale:
Instruct the child to perform controlled breathing exercises. Controlled breathing exercises might be useful for anxiety and panic management, but in an acute asthma episode, the child's primary need is to open up the airways and improve breathing. Albuterol administration takes precedence over breathing exercises in this situation.
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