A nurse is assisting a child who has multiple closed fractures of the lower extremities due to a motor-vehicle crash.
The nurse should monitor the child for which of the following complications during the first 24 hr after the injury occurred?

Choice A rationale

Administering an antidepressant to the client is an important part of treatment for major depressive disorder. However, it is not the first action the nurse should take.

Choice B rationale

Encouraging the client to attend a group therapy session can be beneficial for the client’s recovery, but it is not the first action the nurse should take.

Choice C rationale

Assisting the client in completing his ADLs can help the client maintain a sense of normalcy and control, but it is not the first action the nurse should take.

Choice D rationale

Asking the client if he is considering harming himself is the first action the nurse should take. This is because safety is the top priority, and the nurse needs to assess the client’s risk for suicide.

Choice A rationale

A toddler repeatedly refusing to let a nurse auscultate his lungs is not necessarily an indicator of child abuse. It could be due to fear, discomfort, or lack of understanding about the procedure.

Choice B rationale

An 8-month-old infant crying when his parents leave the room is a normal developmental behavior known as separation anxiety, and it is not an indicator of child abuse.

Choice C rationale

A mother hesitating to comfort her 6-month-old infant could be due to various reasons, including stress, depression, or lack of knowledge about infant care. While it could potentially be a sign of neglect, it is not a definitive indicator of child abuse.

Choice D rationale

A toddler having bruises on his knees is a common occurrence due to their active nature and frequent falls. However, if the bruises are frequent, unexplained, or have distinct patterns, they could be potential indicators of child abuse.