A toddler is brought by a parent to the health department for scheduled immunizations. The toddler clings to the caregiver and cowers when approached. Which assessment warrants immediate intervention by the nurse?

Small bruises on the lower extremities.

A one-inch laceration across center of forehead.

Refusal to answer simple questions.

Several dime-sized circular burns on the back.

Answer and Explanation

The Correct Answer is D

A) Small bruises on the lower extremities:
While bruises should be noted and monitored, small bruises on the lower extremities are relatively common in toddlers due to their active nature and frequent minor falls. They do not immediately indicate abuse unless accompanied by other signs.

B) A one-inch laceration across the center of the forehead:
A laceration, especially if it's recent, should be assessed for proper care and treatment. However, a laceration alone does not necessarily indicate abuse and is less urgent compared to signs of possible abuse such as burns.

C) Refusal to answer simple questions:
A toddler’s reluctance to answer questions might be due to shyness or anxiety related to the visit or the situation. This behavior alone does not indicate an immediate need for intervention unless accompanied by other signs of distress or harm.

D) Several dime-sized circular burns on the back:
Circular burns are a significant concern as they are characteristic of burn injuries that may result from abuse, such as being burned by a hot object or liquid. This finding warrants immediate intervention and further investigation to ensure the child’s safety and well-being.

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Correct Answer is A

Explanation

A. Wear a N95 respirator mask during direct contact with others:
SARS is a viral respiratory illness that spreads via respiratory droplets, and an N95 respirator mask is specifically designed to filter out airborne particles, including those that could carry the SARS virus. Wearing an N95 respirator is critical for preventing the transmission of SARS to others, especially in healthcare settings or close contact situations.

B. Cover mouth and turn head when coughing:
Covering the mouth and turning the head helps reduce the spread of droplets, but it is not sufficient to prevent transmission of airborne viruses like SARS. For effective prevention, especially in a healthcare setting, more stringent measures like using N95 respirators are required.

C. Use meticulous hand washing technique:
Hand washing is crucial for preventing the spread of many infections, but it does not directly address the airborne transmission of viruses like SARS. While it complements other infection control measures, it is not the primary method for preventing SARS transmission.

D. Discard all tissues used during coughing in a biohazard bag:
Proper disposal of tissues is important for infection control, but it alone does not prevent the airborne spread of SARS. This measure is part of broader infection control practices but is less effective in preventing transmission compared to the use of N95 respirators.

A. Ensure that all meals delivered to persons receiving Meals-on-Wheels include fresh or canned fruit. B. Schedule blood pressure screenings during craft club hours for elderly women at the senior center. C. Lobby the local school board to increase physical education classes at all schools in the district. D. Collaborate with a local scout troop to determine families that need wheelchair ramps installed.

Correct Answer is C

Explanation

A) Ensure that all meals delivered to persons receiving Meals-on-Wheels include fresh or canned fruit:
While ensuring meals include fruit can contribute to overall nutrition, it does not specifically address the prevention of osteoporosis. Osteoporosis prevention strategies typically focus on calcium and vitamin D intake and weight-bearing exercises rather than just including fruit in meals.

B) Schedule blood pressure screenings during craft club hours for elderly women at the senior center:
Blood pressure screenings are important for managing cardiovascular health but do not directly impact the prevention of osteoporosis. Osteoporosis prevention strategies are more focused on factors such as bone density, calcium intake, and physical activity.

C) Lobby the local school board to increase physical education classes at all schools in the district:
Increasing physical education classes in schools is a key strategy for osteoporosis prevention. Weight-bearing exercises and physical activity are essential for building and maintaining bone density, especially in youth. Lobbying for increased physical education supports long-term bone health by promoting regular exercise from an early age.

D) Collaborate with a local scout troop to determine families that need wheelchair ramps installed:
While installing wheelchair ramps is important for accessibility and mobility, it does not directly contribute to osteoporosis prevention. Osteoporosis prevention focuses on improving bone health through dietary changes and physical activity rather than addressing mobility issues.

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A toddler is brought by a parent to the health department for scheduled immunizations. The toddler clings to the caregiver and cowers when approached. Which assessment warrants immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A community health nurse is planning strategies to prevent an increase in the incidence of osteoporosis in the community. Which activity should the nurse include?

Correct Answer is C

Explanation

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