A school nurse is assessing a 7-year-old student. The nurse should identify which of the following findings as a potential indicator of physical abuse?
Abrasions on the knees
Front deciduous teeth missing
Weight in 45th percentile
Bruising around the wrists
The Correct Answer is D
A) Abrasions on the knees could result from normal childhood activities and may not indicate physical abuse.
B) Front deciduous teeth missing could be due to normal tooth loss.
C) Weight in the 45th percentile is within a normal range and does not necessarily indicate physical abuse.
D) Bruising around the wrists is concerning for physical abuse, especially in a pattern consistent with restraining or gripping.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Packed red blood cells should typically be infused within 4 hours to reduce the risk of bacterial contamination and ensure potency.
B. Dextrose 5% in water is not typically infused with packed RBCs; the focus is on administering blood products as prescribed.
C. Blood products are typically stored under controlled conditions and transfused promptly after verification and compatibility checks.
D. Filtered IV tubing is often used for blood transfusions to minimize the risk of air embolism and particle infusion, but it's not the primary intervention listed for the scenario.
Correct Answer is D
Explanation
Rationale:
A. Providing the child with a warm blanket can help keep the child comfortable during the course of the illness but initiating airborne precautions is best intervention required.
B. Assessing the oral cavity for Koplik spots is not relevant for varicella, as Koplik spots are associated with measles.
C. Administering aspirin for fever is contraindicated in children with varicella due to the risk of Reye's syndrome.
D. The nurse should initiate airborne precautions, which include placing the child in a private room with negative air pressure, wearing a mask or respirator when entering the room, and limiting visitors and staff exposure. Airborne precautions prevent the transmission of varicella through small droplets that can remain suspended in the air for long periods of time.
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