A nurse in an urgent care clinic is collecting data from a group of clients. Which of the following findings should alert the nurse to the possibility of child maltreatment?
A 6-year-old child who is toilet trained and bedwetting
An 8-month-old infant who has stranger anxiety
An 18-month-old child who has several bruises on their shins
A 2-year-old child who kicks and screams when their parent leaves
The Correct Answer is A
A. Bedwetting in a toilet-trained child can be a sign of emotional distress or trauma, which may indicate maltreatment and should be further investigated.
B. Stranger anxiety is a normal developmental stage for an 8-month-old infant and does not suggest maltreatment.
C. Bruises on the shins of an 18-month-old child are common due to normal toddler activity and do not necessarily indicate maltreatment.
D. Separation anxiety, including kicking and screaming when a parent leaves, is typical behavior for a 2-year-old child and does not suggest maltreatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Swelling in a dependent position is expected due to gravity and should reduce with elevation.
B. Pain following range-of-motion exercises can be normal after a fracture, but persistent or severe pain should be monitored.
C. Coolness of the toes indicates impaired circulation, which can be a sign of compartment syndrome or cast tightness and requires immediate medical attention.
D. Pruritus under the cast is a common complaint and can be managed with appropriate measures but does not require urgent reporting.
Correct Answer is []
Explanation
Potential Condition: Increased intracranial pressure
Actions to Take:
Measure head circumference: This action is important to monitor for signs of increasing intracranial pressure, as a bulging and tense fontanel suggests possible hydrocephalus or other intracranial pathology.
Plan to assist with administration of antibiotics: Antibiotics may be necessary if there is suspected meningitis or another infectious cause contributing to increased intracranial pressure.
Parameters to Monitor:
Behavioral changes: Monitor for irritability, difficulty to console, and other behavioral changes which can indicate neurological distress.
Pupillary response: Assess for changes in pupillary size and reactivity, as altered pupillary responses can indicate neurological involvement and increased intracranial pressure.
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