A nurse recognizes unexplained fussiness and irritability in an infant, as well as unexplained injuries. The nurse should suspect which of the following?
Sexual abuse
Neglect
Munchausen syndrome by proxy
Shaken baby syndrome
The Correct Answer is D
A. Sexual abuse: While sexual abuse can cause physical and emotional symptoms, the combination of unexplained injuries and fussiness/irritability is more suggestive of physical trauma.
B. Neglect: Neglect involves failure to provide for the child's basic needs, which can lead to developmental issues, but is less likely to cause unexplained injuries.
C. Munchausen syndrome by proxy: Munchausen syndrome by proxy involves a caregiver fabricating or inducing illness in a child for attention. It can cause unexplained injuries, but the focus is more on medical symptoms.
D. Shaken baby syndrome: Shaken baby syndrome results from violently shaking an infant, leading to physical injuries, irritability, and fussiness. It fits the description of unexplained injuries and behavioral changes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Cannabis: While cannabis can alter perception and cause depersonalization, it is less likely to cause violent behavior and flashbacks.
B. Heroin: Heroin is a depressant that typically causes sedation and euphoria, not heightened awareness or violent behavior.
C. Cocaine: Cocaine is a stimulant that can cause heightened awareness but is less associated with depersonalization and flashbacks.
D. Phencyclidine (PCP): PCP is known to cause severe alterations in perception, depersonalization, unpredictable and violent behavior, and flashbacks.
Correct Answer is C
Explanation
A. Ignore the incident since it is an attention-seeking behavior: Ignoring the incident is not appropriate because the client may be in distress or at risk of harm.
B. Stay with the group and ask another client to go and check on the situation: Asking another client to check on the situation is not appropriate, as it is the nurse's responsibility to ensure the safety of all clients.
C. Follow the client to determine the cause of the behavior: Following the client allows the nurse to assess and intervene appropriately to ensure the client's safety and address the cause of the behavior.
D. Ask the group what they think about the client's behavior: Discussing the behavior with the group is not appropriate in an emergency situation and does not address the immediate needs of the distressed client.
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