A school nurse is taking care of an adolescent who presents with multiple burns in various stages of healing. which of the following behaviors should the nurse identify as a suggestive of possible physical abuse?

Provides a detailed description of how the burns occurred

Denies discomfort during assessment of injuries

Describes strong relationships with peers

Expresses a reluctance to leave home

Answer and Explanation

The Correct Answer is B

A. Providing a detailed description of how burns occurred may suggest a plausible explanation, but it does not necessarily indicate abuse.

B. Denying discomfort despite the presence of burns may suggest emotional detachment or an attempt to conceal the severity of the injuries, which can be indicative of abuse.

C. Describing strong relationships with peers is a typical and healthy sign of social development and does not indicate abuse.

D. Reluctance to leave home may suggest anxiety or attachment to family, but it is not necessarily indicative of abuse.

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Correct Answer is A

Explanation

A. Rheumatic fever can develop after a group A streptococcal throat infection (strep throat), typically 2 to 4 weeks after exposure. The sibling with a recent sore throat is likely the source of the infection.

B. Fifth disease is caused by parvovirus B19 and is not linked to the development of rheumatic fever.

C. Gastritis is unrelated to rheumatic fever, which stems from a streptococcal throat infection.

D. Chickenpox is caused by varicella zoster virus and does not lead to rheumatic fever.

A. Abdominal pain rated 4 on a scale of 0 to 10 B. Respiratory rate 20/min. C. Blood pressure 93/50 mm Hg D. Heart rate 72/min

Correct Answer is C

Explanation

A. Abdominal pain rated 4 is moderate and should be managed but is not as immediately critical as hypotension.

B. A respiratory rate of 20/min is within normal limits for an adolescent and is not a priority finding.

C. Low blood pressure (hypotension) following blunt abdominal trauma is a concern for internal bleeding or hemorrhage. This is the priority finding and requires immediate intervention.

D. A heart rate of 72/min is normal and does not indicate immediate concern.

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A school nurse is taking care of an adolescent who presents with multiple burns in various stages of healing. which of the following behaviors should the nurse identify as a suggestive of possible physical abuse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has rheumatic fever. When obtaining the child's medical history from the parent, the nurse should recognize the significance of which of the following data as the possible source of the child's infection?

Correct Answer is A

Explanation

A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority?

Correct Answer is C

Explanation

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