When obtaining a history from parents of a 4-year-old child, what indicator should prompt the nurse to consider suspected child abuse?

Consistent growth pattern on the 25th percentile

A contusion on the child's leg

Fearful behavior when the nurse enters the room

Inconsistent story on the child's injury.

Answer and Explanation

The Correct Answer is D

Choice A reason: A consistent growth pattern on the 25th percentile is not an indicator of child abuse. It means that the child is growing normally and is within the expected range for their age and gender.

Choice B reason: A contusion on the child's leg is not necessarily an indicator of child abuse. It could be a result of accidental injury or normal play. However, the nurse should assess the location, size, shape, and color of the bruise, and compare it with the parents' explanation.

Choice C reason: Fearful behavior when the nurse enters the room is not a specific indicator of child abuse. It could be a sign of anxiety, shyness, or discomfort in an unfamiliar setting. The nurse should try to establish rapport with the child and use developmentally appropriate communication techniques.

Choice D reason: An inconsistent story on the child's injury is a strong indicator of child abuse. It suggests that the parents are trying to hide or cover up the cause of the injury, or that they are not aware of how the injury occurred. The nurse should document the discrepancies and report any suspicions of abuse to the appropriate authorities.

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Correct Answer is D

Explanation

Choice A reason: The child's current vital signs are not a reliable indicator of pain, as they may vary depending on the child's condition, medication, and stress level. Vital signs alone are not sufficient to assess pain in children.

Choice B reason: The child becoming quiet when held and cuddled may indicate that the child is comforted by the nurse's presence and touch, not that the child is in pain. In fact, some children may become more vocal and restless when they are in pain.

Choice C reason: The child having just returned from the recovery room does not necessarily mean that the child is in pain. The child may have received pain medication during or after the surgery, or the child may have a different pain threshold. The nurse should not assume that the child is in pain based on the procedure alone.

Choice D reason: The child lying rigidly in bed and not moving is a sign of pain in children, as they may try to avoid movement that could aggravate their pain. The child may also exhibit facial expressions, such as grimacing, frowning, or clenching their teeth, that indicate pain. The nurse should assess the child's pain level and administer pain medication as ordered.

A. Stridor B. Wheezes C. Crackles D. Rhonchi

Correct Answer is A

Explanation

Choice A reason: Stridor is a high-pitched, harsh sound that occurs during inspiration. It is caused by the narrowing of the upper airway due to inflammation and edema. Stridor is a characteristic sign of croup, also known as laryngotracheobronchitis.

Choice B reason: Wheezes are high-pitched, musical sounds that occur during expiration. They are caused by the narrowing of the lower airway due to bronchoconstriction or mucus. Wheezes are more common in asthma than in croup.

Choice C reason: Crackles are fine, crackling sounds that occur during inspiration. They are caused by the opening of collapsed or fluid-filled alveoli. Crackles are more common in pneumonia or heart failure than in croup.

Choice D reason: Rhonchi are low-pitched, snoring sounds that occur during expiration. They are caused by the vibration of mucus in the large airways. Rhonchi are more common in bronchitis or cystic fibrosis than in croup.

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When obtaining a history from parents of a 4-year-old child, what indicator should prompt the nurse to consider suspected child abuse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

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