A 2-month-old is brought into the emergency room. Which factor leads the RN to suspect abusive head trauma?
Sunken fontanels
Retinal hemorrhage
Laceration to forearm.
Large bruises on the body
The Correct Answer is B
A. Sunken fontanels: Sunken fontanels are typically associated with dehydration rather than abusive head trauma.
B. Retinal haemorrhage: Retinal haemorrhages are a key indicator of abusive head trauma, such as shaken baby syndrome. They are caused by the shearing forces of rapid acceleration and deceleration.
C. Laceration to forearm: While concerning, a laceration to the forearm is not specific to abusive head trauma and could result from various types of trauma.
D. Large bruises on the body: While large bruises might indicate physical abuse, they are not specific to head trauma and do not point as directly to abusive head trauma as retinal haemorrhages do.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Wash the cord daily with mild soap and water. Incorrect because keeping the area dry is crucial; soap can irritate the area.
B. Cover the cord with the diaper. Incorrect because it may trap moisture and cause irritation or infection.
C. Apply petroleum jelly to the cord stump. Incorrect because this may keep the area too moist and prevent it from drying and falling off naturally.
D. Give a sponge bath until the cord stump falls off. This prevents the cord from getting wet, which can increase the risk of infection and delay drying and detachment.
Correct Answer is D
Explanation
A. Playing on the backyard swings and running around outside are exercises our child will really enjoy. Encouraging physical activity is beneficial as it helps with lung function and overall health.
B. Three to four times a day we will perform chest therapy and postural drainage on our child. This is correct and necessary to help clear mucus from the lungs.
C. A high protein, high-calorie diet may need to be supplemented with a high-calorie formula. This is important for meeting the nutritional needs of children with cystic fibrosis due to their higher caloric requirements.
D. Pancreatic enzymes will not be necessary if our child has a good appetite and regular bowel movements. This is incorrect; children with cystic fibrosis typically need pancreatic enzyme supplements with every meal and snack to aid digestion, regardless of appetite or bowel regularity.
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