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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Characteristics of families in the upper-middle class:
Understanding the characteristics of families in a specific income bracket can provide useful context, but it does not directly address the distribution of income within the community. The focus should be on the entire income range and how it affects the community's needs.
B. The reliability of such a high average family income:
While it's important to consider the accuracy of data, this question is more about how the range and distribution of income affect the community. The reliability of the data is less relevant than understanding the income distribution.
C. The frequency of incomes above and below the average:
Assessing the frequency of incomes above and below the average provides a better understanding of income distribution within the community. This information helps identify socioeconomic disparities and guide targeted interventions or resources needed for different income groups.
D. Interventions focused on college-educated individuals:
Focusing on college-educated individuals may be relevant in some contexts, but it does not address the broader issue of income distribution. Understanding the frequency of different income levels is more directly related to addressing the needs of the community based on their income range.
Correct Answer is C
Explanation
A. Renal insufficiency: While annual screening for renal insufficiency is important for individuals with diabetes to detect early signs of diabetic nephropathy, it is not as directly related to the immediate risks associated with smoking and family history of heart disease.
B. Peripheral neuropathy: Screening for peripheral neuropathy is essential for diabetes management, but it is not the most critical in the context of the client's smoking history and family history of early heart disease.
C. Hyperlipidemia: Given the client’s significant risk factors—including smoking two packs of cigarettes daily and a family history of early cardiovascular events—it is crucial to screen for hyperlipidemia. Smoking and a family history of early heart attack both increase the risk of cardiovascular disease, which is often associated with high cholesterol levels. Addressing hyperlipidemia can help mitigate the risk of cardiovascular complications.
D. Retinopathy: Screening for diabetic retinopathy is important for managing diabetes and preventing vision problems. However, in the context of the client's smoking and family history, addressing hyperlipidemia is a more immediate concern related to cardiovascular health.
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