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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Assess motor function in lower extremities: While important for overall neurological assessment, immediate post-repair monitoring of motor function is secondary to monitoring for signs of hydrocephalus (head circumference).
B. Maintain skin integrity: Essential for preventing infection but does not address the immediate post-surgical complication of hydrocephalus.
C. Monitor intake and output: Important for general post-operative care but does not address the immediate concern of monitoring for hydrocephalus.
D. Monitor head circumference: Following repair of a myelomeningocele, infants are at risk for developing hydrocephalus due to abnormal cerebrospinal fluid dynamics. Monitoring head circumference helps detect early signs of increased intracranial pressure, a common complication post-surgery.

Correct Answer is []

Explanation

Complication: Otitis Media

Anatomical Changes:

Small external ear structure: Infants born with a cleft palate often have smaller external ear structures, which can affect the drainage of fluids and increase the risk of infections.
Horizontal eustachian tubes: Eustachian tubes in individuals with cleft palate are typically more horizontal than normal, impairing the drainage of fluid from the middle ear.
Large tongue: A large tongue may obstruct the upper airway and interfere with normal swallowing and speaking functions.

Complication: Otitis Media

Due to the anatomical changes associated with cleft palate, such as horizontal eustachian tubes and impaired drainage, individuals are prone to recurrent middle ear infections (otitis media). These infections can lead to fluid accumulation behind the eardrum, which can further impair hearing and potentially lead to more serious complications if untreated.

Priority Interventions:

Ear drops (for otitis media): Ear drops containing antibiotics may be prescribed to treat bacterial infections in the middle ear, which are common in individuals with cleft palate.
- Rationale: Ear drops help to directly treat the infection in the ear canal and middle ear, reducing inflammation and preventing complications such as hearing loss or spread of infection.
Corticosteroids (for inflammation): Corticosteroids may be used to reduce inflammation in the ear canal and middle ear, particularly in cases of severe otitis media.
- Rationale: Corticosteroids help to decrease swelling and inflammation, which can improve symptoms and aid in the healing process of the ear.

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Which of the following clients would the nurse report as a suspected abuse case?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the priority nursing intervention to perform on an infant immediately following repair of a myelomeningocele?

Correct Answer is D

Explanation

Identify a complication resulting from a cleft palate, the anatomical changes that lead to the complication, and the priority interventions for care.

Correct Answer is []

Explanation

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Which of the following factors would the nurse identify as risk factors for abuse in children? (Select All that Apply.)