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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Take a time-out: A time-out is generally used for de-escalating situations in less severe cases and may not be effective if the client is already physically aggressive and a risk to staff.
B. Administer oral medication: Administering oral medication can help to calm the client, but it may not be immediately effective if the client is already aggressive and out of control.
C. Call a family member or friend: Calling a family member or friend may provide emotional support, but it is not a direct intervention to address immediate physical aggression.
D. Apply restraints: When a client is physically aggressive and poses a risk of injury to themselves or others, applying restraints may be necessary to ensure safety. This should be done following proper protocols and as a last resort.
Correct Answer is B
Explanation
A. Facilitate time alone for the client. Allowing time alone is not appropriate for a suicidal client as it increases the risk of self-harm.
B. Make a no self-harm contract. A no self-harm contract can be part of a suicide prevention plan, where the client agrees to not harm themselves and to seek help if they feel the urge to do so.
C. Administer antianxiety medication: While medication can help with anxiety, it is not a primary intervention for immediate suicide prevention.
D. Prevent family/friend visitation for 48 hours: Preventing visitation can increase feelings of isolation and is not an appropriate intervention for suicide prevention.
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