A nurse is caring for a 5-year-old child who is withdrawn and has bruising on the ear and neck.
Which of the following actions should the nurse take first?
Discuss the bruises with the child's parent.
Report the bruises to child protective services.
Complete a full physical assessment of the child.
Document the bruise in the child's medical record.
The Correct Answer is C
This scenario involves a potential pediatric abuse situation requiring immediate nursing intervention. Application of the nursing process (assessment before action) and legal mandates for reporting suspected maltreatment is necessary to determine the priority step when physical indicators of injury are observed.
Choice A rationale
Discussing bruises with a parent may be necessary later, but it is not the immediate priority. If abuse is occurring, confronting the parent before completing a thorough assessment or ensuring child safety could potentially put the child at further risk.
Choice B rationale
Reporting to protective services is mandatory, but the nurse must first gather all clinical evidence. A complete physical exam provides the detailed data needed for an accurate and comprehensive report, ensuring all injuries are documented before the report is filed.
Choice C rationale
The nurse must first assess the child to identify the full extent of injuries and ensure physical stability. Systematic assessment allows for the discovery of hidden bruises or fractures, which is essential for both medical treatment and legal documentation.
Choice D rationale
Documentation is essential for legal and clinical purposes but follows the actual assessment. The nurse cannot document the full clinical picture accurately without performing a head-to-toe examination first to find all potential markers of physical trauma.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
School-age development involves the refinement of gross and fine motor skills and the achievement of specific cognitive milestones. Understanding the chronological progression of balance, coordination, and self-care abilities is required to assess whether a child is meeting expected developmental benchmarks.
Choice A rationale
Counting backward from 20 to 1 is a cognitive milestone rather than a motor skill development. While this skill is usually achieved by age 7, the question specifically focuses on the physical motor development of the school-aged child.
Choice B rationale
Most children develop the fine motor coordination required to dress and groom themselves, including managing buttons and zippers, by age 5. By age 6, this skill is typically well-established rather than just beginning to emerge.
Choice C rationale
The safe and effective use of complex tools like screwdrivers or hammers requires advanced hand-eye coordination and muscle strength usually developed later in the school-age years, typically between ages 9 and 12, rather than at age 6.
Choice D rationale
By age 6, children have improved gross motor coordination and equilibrium. Activities such as jumping rope, hopping on one foot, and riding a bicycle require the specific balance and rhythmic coordination characteristic of this developmental stage.
Correct Answer is C
Explanation
Intussusception involves the telescoping of one intestinal segment into another, causing lymphatic and venous obstruction. Knowledge of gastrointestinal manifestations is critical to identify life-threatening ischemia and bowel necrosis in infants presenting with sudden abdominal pain and stool changes.
Choice A rationale
Projectile vomiting is a characteristic clinical finding of hypertrophic pyloric stenosis, not intussusception. It results from gastric outlet obstruction due to muscular thickening, occurring without the presence of bile, typically seen in infants aged three to six weeks.
Choice B rationale
Severe diarrhea typically indicates infectious gastroenteritis or malabsorption syndromes. In intussusception, the bowel is obstructed by the invagination process, which usually prevents the passage of normal diarrheal stools as the intestinal lumen becomes physically blocked and compressed.
Choice C rationale
Currant-jelly stools contain a mixture of blood and mucus, occurring as the compressed intestinal mucosa sheds. This classic hallmark reflects venous congestion and ischemia within the intussusceptum, indicating a high risk for impending bowel perforation and necrosis.
Choice D rationale
Bilious vomiting suggests a distal intestinal obstruction but is not specific to intussusception. While it can occur as the condition progresses, it lacks the diagnostic specificity of the vascular-related stool changes that define the classic clinical presentation.
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