A charge nurse is teaching a group of nurses about identifying child abuse. Which of the following findings should the nurse identify as a potential indicator of child abuse?
A toddler repeatedly refuses to let a nurse auscultate his lungs.
A mother is hesitant to comfort her 6-month-old infant.
A toddler has bruises on his knees.
An 8-month-old infant cries when his parent leaves the room.
The Correct Answer is A
A. A toddler's repeated refusal to let a nurse perform a routine medical assessment may indicate fear or discomfort around adults, which could be a potential indicator of child abuse or neglect.
B. A mother's hesitation to comfort her 6-month-old infant may be due to various reasons, such as cultural differences, lack of confidence, or personal preferences. It is not necessarily indicative of child abuse.
C. Bruises on a toddler's knees are a common finding in active children who are learning to walk and explore their environment. While bruises should always be assessed, they are not automatically indicative of child abuse.
D. An 8-month-old infant crying when a parent leaves the room is a normal separation anxiety response for an infant of this age and is not indicative of child abuse. This behavior is part of normal infant development.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A respiratory rate of 28 breaths per minute indicates increased respiratory effort, which can be a sign of moderate dehydration. The infant may be trying to compensate for fluid
loss.
B. Capillary refill of 1 second is within the normal range (less than 2 seconds). It is not indicative of moderate dehydration.
C. Weight loss of 7% is a significant amount of weight loss and is indicative of severe dehydration, not moderate dehydration. Moderate dehydration is usually defined as 5- 10% weight loss.
D. Bradycardia (slow heart rate) is not typically associated with dehydration. In fact, tachycardia (fast heart rate) is a more common sign of dehydration.
Correct Answer is C
Explanation
A. A blood pressure of 132/82 mm Hg in an adolescent is within the normal range for their age group. It does not require immediate reporting to the provider.
B. A respiratory rate of 30 breaths per minute in a 3-month-old infant is within the expected (typically 25-40 breaths per minute).
C. A heart rate of 68 beats per minute in an 18-month-old toddler is below the normal range (typically 70-110 beats per minute) and should be reported g to the provider.
D. A rectal body temperature of 37.3° C (99.1° F) in a school-age child is within the normal range (typically 36.5-37.5° C or 97.7-99.5° F). It does not require immediate reporting to the provider.
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