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. Residual fluid should not be discarded unless instructed by a healthcare provider, as it provides important information about gastric emptying and tolerance to previous feedings.
B. Formula should be brought to room temperature before administration to avoid causing discomfort or gastric irritation. Cold formula can cause cramps and slow gastric motility.
C. Elevating the head of the bed to a 45-degree angle helps prevent aspiration during feeding and promotes proper digestion. This position is critical for patient safety.
D. The feeding rate should be individualized based on the child's tolerance and prescribed regimen, and 30 mL/min is typically too fast for a preschooler, increasing the risk of aspiration or intolerance.
Correct Answer is C
Explanation
A. Sharing toys readily is more common in older preschoolers and school-age children.
B. Having an imaginary playmate typically occurs in children slightly older than 24 months.
C. Parallel play, where children play alongside each other without interacting, is typical for toddlers around 24 months.
D. Asking many questions is more characteristic of preschool-aged children.
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