An Asian family arrives with their newborn for a well visit. When assessing the infant, the nurse observes the following skin irregularity. What is the nurse's priority action?
Notify child protective services
Record the finding
Notify the healthcare provider
Interview the clients about the injury
The Correct Answer is B
Choice A Reason: Notifying child protective services is not the priority action, as it is not indicated by the skin irregularity. The skin irregularity is most likely a Mongolian spot, which is a benign, bluish-gray or purple patch of pigmentation that is common in infants of Asian, African, or Hispanic descent. It is not a sign of abuse or injury, but rather a normal variation of skin color.
Choice B Reason: This is the correct choice. Recording the finding is the priority action, as it documents the presence and location of the Mongolian spot and prevents confusion or misdiagnosis in the future. The Mongolian spot usually fades by age 2 to 4 years, but it may persist into adulthood.
Choice C Reason: Notifying the healthcare provider is not the priority action, as it is not necessary for the skin irregularity. The skin irregularity is not a cause for concern or intervention, but rather a normal variation of skin color.
Choice D Reason: Interviewing the clients about the injury is not the priority action, as it is not appropriate for the skin irregularity. The skin irregularity is not an injury, but rather a normal variation of skin color. Interviewing the clients about it may imply suspicion or accusation of abuse, which can damage the nurse-client relationship and trust.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because portal hypertension means that there is high blood pressure in the portal vein, which carries blood from the digestive organs to the liver. When the liver is damaged by hepatitis, it becomes scarred and obstructs the blood flow, causing increased pressure in the portal vein. This leads to fluid accumulation in the abdomen, called ascites, which causes abdominal swelling.
Choice B reason: This is incorrect because portal hypertension is not caused by the heart overworking but by liver damage. The heart does not pump blood into the portal vein, but into the hepatic artery, which supplies oxygenated blood to the liver.
Choice C reason: This is incorrect because portal hypertension does not develop when cirrhosis begins to resolve, but when it progresses. Cirrhosis is a chronic condition that causes irreversible scarring of the liver tissue, which worsens over time and increases portal hypertension.
Choice D reason: This is incorrect because eating high-sodium foods and a stressful lifestyle do not cause portal hypertension, but they can aggravate it. High-sodium foods can increase fluid retention and worsen ascites, while stress can increase blood pressure and worsen bleeding complications. The nurse should advise the client to limit sodium intake and manage stress levels.
Correct Answer is C
Explanation
Choice A Reason: Seasonal allergies are not a cause of delirium, but a common condition that affects the respiratory system and causes symptoms such as sneezing, runny nose, itchy eyes, or coughing.
Choice B Reason: History of GERD is not a cause of delirium, but a chronic condition that affects the digestive system and causes symptoms such as heartburn, regurgitation, chest pain, or difficulty swallowing.
Choice C Reason: Benzodiazepines are a cause of delirium, especially in older adults or those with cognitive impairment. Benzodiazepines are a class of drugs that act on the central nervous system and cause sedation, relaxation, and reduced anxiety. However, they can also impair memory, attention, orientation, and judgment, and lead to confusion, agitation, hallucinations, or delusions.
Choice D Reason: Completed antibiotics 10 days ago are not a cause of delirium, but a treatment for bacterial infections. Antibiotics can have side effects such as nausea, diarrhea, rash, or allergic reactions, but they do not cause delirium unless they are toxic or interact with other medications.
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