A child presents at the emergency room with signs of neglect and malnutrition. What should be the nurse's immediate action?

Provide a meal and send the child home with instructions for better nutrition

Report the case to child protective services while ensuring the child's immediate needs are met

Call the child's parents to discuss the situation

Wait for further evidence of neglect before taking any action

Answer and Explanation

The Correct Answer is B

Choice A reason: Providing a meal and discharging ignores neglect’s broader impact. Malnutrition and neglect elevate cortisol, risking developmental delays. Scientifically, addressing only immediate nutrition fails to protect the child from ongoing harm, as unaddressed abuse can exacerbate psychological trauma and physical health deficits, delaying recovery.

Choice B reason: Reporting to child protective services while meeting immediate needs ensures safety and addresses neglect. Malnutrition disrupts metabolic and cognitive function, while abuse elevates stress hormones. Scientifically, prompt reporting triggers protective interventions, stabilizing the child’s neurobiological stress responses and supporting physical and psychological recovery.

Choice C reason: Calling parents risks escalating harm, as they may be the neglect source. Scientifically, premature contact can increase the child’s stress, elevating cortisol and worsening trauma-related symptoms. This delays protective interventions, leaving the child vulnerable to ongoing neglect and its neurobiological consequences, like developmental delays.

Choice D reason: Waiting for further evidence delays protection, risking ongoing harm. Neglect’s impact, like malnutrition, disrupts brain development and increases cortisol. Scientifically, delaying action fails to address trauma’s neurobiological effects, allowing continued physical and psychological harm, compromising the child’s safety and long-term well-being.

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Correct Answer is A

Explanation

Choice A reason: A mental status exam evaluates cognitive and emotional functioning, identifying acute stress disorder symptoms like dissociation or hyperarousal. Scientifically, it maps neurobiological changes, like amygdala hyperactivity, guiding targeted interventions. This ensures accurate diagnosis, addressing trauma’s psychological impact and preventing progression to PTSD through timely care.

Choice B reason: Encouraging detailed trauma discussion may re-traumatize the client, intensifying stress. Acute stress disorder involves heightened amygdala activity and cortisol spikes. Scientifically, premature processing can exacerbate symptoms, like flashbacks, disrupting emotional regulation and delaying recovery by overwhelming the client’s coping mechanisms early in treatment.

Choice C reason: Administering medication immediately without assessment risks inappropriate treatment. Anxiety in acute stress disorder stems from neurobiological stress responses. Scientifically, premature medication may disrupt neurotransmitter balance, potentially worsening symptoms if the underlying trauma’s severity or type isn’t evaluated, delaying effective psychological stabilization.

Choice D reason: Reassuring quick recovery is unrealistic and dismissive, as acute stress disorder recovery varies. Scientifically, false reassurance may increase anxiety, as unaddressed trauma-related neural changes, like cortisol elevation, persist. This undermines trust, delaying engagement with effective interventions needed to stabilize the client’s mental state post-trauma.

Correct Answer is ["10"]

Explanation

Step 1 is: 40 mg ÷ 20 mg

Step 2 is: (40 ÷ 20) = 2

Step 3 is: 2 × 5 mL = 10 mL

Final answer = 10 mL

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A child presents at the emergency room with signs of neglect and malnutrition. What should be the nurse's immediate action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has recently experienced a traumatic event and is showing signs of acute stress disorder. Which of the following nursing actions should the nurse prioritize to promote recovery?

Correct Answer is A

Explanation

A nurse is preparing to administer fluoxetine 40 mg PO daily. The amount available is fluoxetine 20 mg/5mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["10"]

Explanation

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