A nurse is reviewing the medical records of a group of clients. Which of the following findings should the nurse report to local authorities?
A 6-month-old infant who has a spiral fracture to a lower extremity.
A 9-month-old infant who has been exposed to bedbugs and has cellulitis.
A 4-year-old preschooler who has a rivalry with their siblings.
A 24-month-old toddler who experiences occasional incontinence.
The Correct Answer is A
Choice A rationale:
The nurse should report the finding of a 6-month-old infant with a spiral fracture to a lower extremity to local authorities. Spiral fractures in infants, especially those who are not yet independently mobile, raise concerns about possible child abuse or non-accidental trauma. The unique pattern of spiral fractures is often associated with twisting forces, which are unlikely to occur accidentally in infants who cannot perform such movements. Reporting such cases is essential to ensure the safety and well-being of the child.
Choice B rationale:
A 9-month-old infant exposed to bedbugs and cellulitis is not an emergency that requires reporting to local authorities. While cellulitis can be serious, it is not an immediate threat to the child's safety, and the focus should be on providing appropriate medical care.
Choice C rationale:
A 4-year-old preschooler with rivalry among siblings does not indicate a need for reporting to local authorities. Sibling rivalry is a common occurrence in families and does not pose a threat to the child's safety. It is a social and developmental issue that can be addressed within the family.
Choice D rationale:
A 24-month-old toddler experiencing occasional incontinence does not require reporting to local authorities. Occasional incontinence can be a normal part of toddler development as they learn to control their bladder. It does not indicate abuse or immediate danger to the child.
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Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Administering an oral corticosteroid is not the first action the nurse should take. Corticosteroids are used to reduce inflammation and itching caused by poison ivy. However, they are usually prescribed if the symptoms are severe or if the rash covers a large area of the body. It’s important to note that corticosteroids can have side effects, especially when used for a long time, so they should be used under the supervision of a healthcare provider.
Choice B rationale: Applying calamine lotion to the affected area can help soothe the skin and relieve itching caused by poison ivy. However, this is not the first action the nurse should take. The first step is to remove the oil from the skin that causes the allergic reaction. Calamine lotion can be applied after the area has been thoroughly washed.
Choice C rationale: Instructing the parent to give the child an oatmeal bath twice daily can help soothe the skin and relieve itching. However, this is not the first action the nurse should take. Similar to calamine lotion, an oatmeal bath can be beneficial after the area has been thoroughly washed to remove the oil from the skin.
Choice D rationale: The first action the nurse should take when caring for a child exposed to poison ivy is to flush the area with cold, running water. This helps to remove the oil (urushiol) from the skin that causes the allergic reaction. It’s important to do this as soon as possible after exposure to help prevent the spread of the oil to other areas of the body or to other people. After flushing the area, the nurse can then apply calamine lotion or recommend an oatmeal bath to help soothe the skin and relieve itching.
Correct Answer is A
Explanation
Choice A rationale:
Pain following range-of-motion exercises is a significant finding that should be reported to the provider. It could indicate the possibility of complications, such as further injury or impaired healing. Adolescents with fractured bones are often encouraged to perform range-of-motion exercises to prevent stiffness and promote circulation. However, increased pain during or after these exercises could indicate problems like muscle strain or improper alignment of the fracture, which need to be addressed promptly.
Choice B rationale:
Pruritus (itching) under the cast is common and can be expected due to the accumulation of dead skin cells and sweat. While it can be uncomfortable for the client, it's not an urgent concern that requires immediate reporting to the provider. Strategies to alleviate itching, such as using a cool blow dryer under the cast, can be taught to the client.
Choice C rationale:
The presence of swelling while the extremity is dependent is a normal response to gravity and is not an alarming finding. Swelling when the extremity is dependent is expected, especially within the initial stages of fracture healing. It suggests that the blood supply is reaching the area for healing purposes. Elevation and rest can help reduce the swelling.
Choice D rationale:
Coolness of the toes could be due to reduced blood flow, but this finding alone may not be an immediate concern. It's essential to consider the client's overall circulation, capillary refill, and presence of pulses. If other signs of impaired circulation, such as pallor or delayed capillary refill, are present along with coolness, it might indicate compromised vascular supply. However, based on the information provided, this choice is not as urgent as reporting pain following range-of-motion exercises.
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