A nurse is assessing a toddler. Which of the following findings should the nurse identify as an indication of potential child maltreatment?
Superficial scrapes on the toddler's lower legs
Circular burns on the soles of the toddler's feet
Irregular area of blue pigmentation over the toddler's sacrum
Single bruise on the toddler's forearm
The Correct Answer is B
A. Superficial scrapes on the toddler's lower legs: These are common in toddlers due to normal play and exploration.
B. Circular burns on the soles of the toddler's feet: Circular burns, especially in unusual areas like the soles, are a hallmark sign of intentional injury and potential abuse.
C. Irregular area of blue pigmentation over the sacrum: This is likely a Mongolian spot, a benign and common finding in children of certain ethnicities.
D. Single bruise on the toddler's forearm: This is not necessarily indicative of abuse, as toddlers frequently sustain minor injuries from routine activities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Chill the medication prior to administration." The medication should be warmed to room temperature to prevent discomfort or dizziness during administration.
B. "Pull the pinna up and back during medication administration." For infants, the pinna should be pulled down and back to straighten the ear canal.
C. "Hyperextend the infant's neck during medication administration." Hyperextending the neck is unnecessary and may cause discomfort; a neutral position is sufficient.
D. "Massage the anterior area of the ear following administration." Massaging the tragus helps ensure the medication is evenly distributed into the ear canal.
Correct Answer is ["A","B","C","D"]
Explanation
Findings that require immediate follow-up:
- Generalized muscle weakness noted in bilateral lower extremities: This could indicate a neurological or muscular issue, such as Guillain-Barré Syndrome (GBS), which is a concern after a viral infection or vaccination. This requires further investigation and close monitoring for any signs of progression, such as worsening weakness or respiratory involvement.
- Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10: This pain could be indicative of muscle cramping or weakness, which may be associated with GBS or another neurological condition. Pain in combination with muscle weakness should be followed up closely.
- Abdomen slightly firm, bowel sounds hypoactive, and reports last bowel movement was 3 days ago: This could suggest constipation or a gastrointestinal issue. However, the gastrointestinal symptoms may be secondary to the muscle weakness (if part of a systemic condition like GBS), and should be monitored, but it’s not as urgent as the neurological findings.
Findings that do not require immediate follow-up:
- Patellar deep tendon reflexes 1+ bilaterally: A 1+ reflex is on the lower end of normal and does not indicate a severe problem by itself.
- Child is awake and alert, responds appropriately to questions: This is a reassuring sign and does not require immediate follow-up.
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