A school nurse is taking care of an adolescent who presents with multiple burns in various stages of healing. which of the following behaviors should the nurse identify as a suggestive of possible physical abuse?
Provides a detailed description of how the burns occurred
Denies discomfort during assessment of injuries
Describes strong relationships with peers
Expresses a reluctance to leave home
The Correct Answer is B
A. Providing a detailed description of how burns occurred may suggest a plausible explanation, but it does not necessarily indicate abuse.
B. Denying discomfort despite the presence of burns may suggest emotional detachment or an attempt to conceal the severity of the injuries, which can be indicative of abuse.
C. Describing strong relationships with peers is a typical and healthy sign of social development and does not indicate abuse.
D. Reluctance to leave home may suggest anxiety or attachment to family, but it is not necessarily indicative of abuse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Acute rheumatic fever can cause carditis, which may lead to heart murmurs, tachycardia, or heart failure. Assessing heart sounds is a priority to identify potential complications.
B. Joint pain is an important concern in acute rheumatic fever, but the immediate priority is assessing for signs of carditis or heart complications.
C. An erythematous rash is a characteristic of acute rheumatic fever but is less critical to address immediately compared to potential cardiac involvement.
D. Parental anxiety should be addressed, but the priority is assessing the child’s physical condition, particularly the heart.
Correct Answer is A
Explanation
A. Decreased attention span is a common manifestation of increased intracranial pressure, as pressure on the brain can affect cognitive function.
B. Hyperactivity is not typically associated with increased intracranial pressure. It would be more common for the child to exhibit lethargy or irritability.
C. Tachycardia is not a primary symptom of increased intracranial pressure. Typically, bradycardia (slow heart rate) is seen in cases of severe intracranial pressure.
D. Hypotension is not usually associated with increased intracranial pressure. In fact, increased intracranial pressure often leads to elevated blood pressure and a widening pulse pressure.
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