A 2-month-old infant is brought to the emergency room.
Which factor should lead the RN to suspect that the child may have experienced abusive head trauma?
Sunken fontanels.
Retinal hemorrhage.
Large bruises on the body.
Laceration to the forearm.
The Correct Answer is B
Choice A rationale
Sunken fontanels are typically a sign of dehydration due to reduced intracranial pressure and are not specific to abusive head trauma. Abusive head trauma often results in elevated intracranial pressure or swelling, which would present differently. Therefore, this finding is unrelated to the mechanisms of abusive head trauma in a 2-month-old.
Choice B rationale
Retinal hemorrhages are strongly associated with abusive head trauma due to the shearing forces during shaking or impact, which rupture retinal blood vessels. This finding is a hallmark of non-accidental trauma in infants, as accidental injuries rarely cause this degree of internal ocular damage.
Choice C rationale
Large bruises on the body could indicate trauma but are not specific to abusive head trauma. Additionally, the pattern or location of bruises is significant for abuse, especially in non-mobile infants. However, bruises alone do not confirm head trauma specifically.
Choice D rationale
Lacerations, such as those on the forearm, might suggest trauma but lack specificity for abusive head trauma. Such injuries are more commonly associated with accidents or other forms of physical abuse that do not necessarily involve the head.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale
Weight gain is a common side effect of corticosteroids due to fluid retention and increased fat deposition. Corticosteroids stimulate appetite and alter fat metabolism, leading to central obesity and moon face, which are classic findings.
Choice B rationale
Mood changes, including irritability, depression, or euphoria, are linked to corticosteroid therapy as these medications affect the central nervous system. Neuropsychiatric symptoms can vary widely and may impact the adolescent’s quality of life and social interactions.
Choice C rationale
Weight loss is not a typical side effect of corticosteroids. These medications are more associated with increased appetite and fat redistribution, leading to weight gain rather than weight loss, making this an incorrect choice.
Choice D rationale
Chronic fatigue is not directly attributed to corticosteroids. While muscle weakness can occur due to protein catabolism, it is not synonymous with fatigue. Corticosteroids often cause insomnia, which could indirectly lead to tiredness, but this is not a primary effect.
Choice E rationale
Osteoporosis is a long-term side effect of corticosteroids due to their impact on calcium metabolism and bone resorption. These medications decrease calcium absorption, increase calcium excretion, and suppress osteoblast activity, leading to reduced bone density.
Correct Answer is A
Explanation
Choice A rationale
Horizontal eustachian tubes in children with cleft palate increase the risk of otitis media due to impaired drainage and ventilation. Surgical closure of the palate helps restore anatomical structure, reducing the incidence of middle ear infections and associated complications.
Choice B rationale
Small external ear structure is not anatomically linked to hydrocephalus, and diuretics are unrelated to managing this condition. Hydrocephalus stems from cerebrospinal fluid accumulation, not external ear anatomy, making this option inaccurate.
Choice C rationale
A large tongue may lead to airway obstruction but is not linked to otitis externa. Ear drops manage external ear infections but do not address anatomical changes associated with cleft palate, which impacts the eustachian tubes and middle ear.
Choice D rationale
An opening in the lip does not directly cause pneumonia. Pneumonia is primarily a respiratory condition influenced by infections, not lip anatomy. Corticosteroids are not standard interventions for pneumonia related to cleft palate complications.
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