A school nurse is examining a child who has a toothache and bruises on both knees.
Which of the following observations should the nurse report as a potential sign of maltreatment at home?

The child is receiving free lunches at school.

The child has recently started experiencing urinary incontinence.

The child has a history of frequent absences from school.

The child appears to be underweight for their age.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While receiving free lunches at school may indicate a low-income status, it does not necessarily suggest maltreatment at home. Many schools offer free or reduced-price lunches to students from low-income families to ensure they receive proper nutrition.

Choice B rationale

Urinary incontinence in a child could be due to various reasons, including medical conditions or stress. While it could potentially be a sign of maltreatment, it is not a definitive indicator and would need to be evaluated in the context of other signs and symptoms.

Choice C rationale

Frequent absences from school can be a potential sign of maltreatment at home. Children who are being maltreated may be kept home to hide physical signs of abuse, or they may be truant due to a lack of parental supervision or a chaotic home environment.

Choice D rationale

Being underweight for their age could be a sign of neglect, one form of maltreatment. However, it could also be due to a variety of other factors, including medical conditions or poor nutrition, and should be evaluated in the context of other signs and symptoms.

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Correct Answer is C

Explanation

Choice A rationale

Providing nutrition education to employees who have a BMI of greater than 30 is an example of primary prevention. It aims to prevent the onset of disease (in this case, obesity-related diseases) by promoting healthy behaviors.

Choice B rationale

Providing education about safety and injury prevention for employees is also an example of primary prevention. It aims to prevent injuries before they occur.

Choice C rationale

Screening employees who have been exposed to high levels of noise for hearing loss is an example of secondary prevention. Secondary prevention aims to identify and treat an illness or disease at an early stage.

Choice D rationale

Coordinating disaster planning efforts at the factory is an example of tertiary prevention. It aims to manage and mitigate the effects of a disaster, which is an existing condition.

A. Client who is ambulatory and exhibits manic behavior B. Client who has a rigid abdomen with manifestations of shock C. Client who has superficial partial thickness burn injuries over 5% of his body D. Client who has a femur fracture with a 2+ pedal pulse

Correct Answer is B

Explanation

Choice A rationale

While manic behavior can be disruptive and may require intervention, it is not typically life- threatening. Therefore, this client would not be the highest priority in a triage situation following a bombing incident.

Choice B rationale

A rigid abdomen with manifestations of shock could indicate serious internal injuries, such as bleeding or organ damage. This client would be a high priority for treatment due to the potential for rapid deterioration and life-threatening complications.

Choice C rationale

Superficial partial thickness burn injuries over 5% of the body, while painful and requiring treatment, are not typically immediately life-threatening. This client would be a lower priority compared to a client with signs of shock and potential internal injuries.

Choice D rationale

A femur fracture with a 2+ pedal pulse indicates that the client has a serious injury, but it is not immediately life-threatening. The presence of a 2+ pedal pulse suggests that circulation to the foot is still intact. This client would be a lower priority compared to a client with signs of shock and potential internal injuries.

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A school nurse is examining a child who has a toothache and bruises on both knees.Which of the following observations should the nurse report as a potential sign of maltreatment at home?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is B

Explanation

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A school nurse is examining a child who has a toothache and bruises on both knees.
Which of the following observations should the nurse report as a potential sign of maltreatment at home?