Which of the following clients would the nurse report as a suspected abuse case?
A 10-year-old with a burn on the palm of the hand
A 6-year-old with splash burns on the front torso
A 4-year-old with circular abrasions around the wrists
A 2-year-old with a large bruise on the forehead
The Correct Answer is C
A. A 10-year-old with a burn on the palm of the hand: This could potentially be accidental, for example, from touching a hot surface. However, while it requires further investigation, it is not as strongly indicative of abuse as the given option.
B. A 6-year-old with splash burns on the front torso: These burns could result from accidentally spilling hot liquids. Though it raises concern, it often indicates an accident rather than abuse unless accompanied by other suspicious signs.
C. A 4-year-old with circular abrasions around the wrists: This is highly suspicious of abuse because circular abrasions can indicate that the child may have been tied or restrained, which is not typical of accidents or normal play.
D. A 2-year-old with a large bruise on the forehead: This type of injury is common in young children who are prone to falls and bumps. It might not immediately suggest abuse without additional context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Tachypnea. Rapid breathing can indicate respiratory distress associated with heart failure.
B. Wheezes or rales. These are abnormal breath sounds indicating fluid in the lungs, which can occur with heart failure.
C. Bounding pulses. Bounding pulses are not typically associated with heart failure; weak pulses may be present due to poor perfusion.
D. Edematous. Edema can occur due to fluid retention, a sign of heart failure.
E. Difficulty feeding. Poor feeding can result from decreased cardiac output affecting systemic circulation and energy for feeding.
F. Increased comfort laying down. Children with heart failure often prefer sitting upright due to respiratory distress.
Correct Answer is C
Explanation
A. Keep the newborn in a well-lit nursery: A well-lit nursery can overstimulate a preterm newborn. Preterm infants benefit more from a dim, quiet environment that mimics the womb.
B. Cluster the newborn's care activities: This helps minimize disruptions to the newborn’s rest periods, which is crucial for their growth and neurodevelopment. Clustering care reduces stress and promotes better sleep cycles.
C. Position the newborn to promote extension of muscles: Preterm infants generally benefit from a flexed position, which is more comforting and developmentally appropriate, rather than promoting muscle extension.
D. Use fingertips when calming the newborn: Using fingertips might be too stimulating for a preterm newborn. Instead, a gentle, whole-hand touch is often more comforting and less likely to cause overstimulation.
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