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 B
Explanation
A) Mortality rate in the community:
The mortality rate is an important indicator of overall health in a community and provides information about the number of deaths over a specific period. While it is useful for identifying trends and health outcomes, it does not capture the immediate and current health concerns or priorities of the community members.
B) Expressed needs of community members:
The expressed needs of community members are crucial for understanding the specific health concerns and priorities of the population. This information helps tailor interventions and programs to address the actual needs and preferences of the community, ensuring that the healthcare strategies implemented are relevant and effective.
C) Life expectancy of clients in the community:
Life expectancy is an important measure of general health and longevity in a community. However, it is a broader measure that does not provide specific insights into current health issues or immediate needs. Understanding life expectancy alone does not address the specific concerns or requirements of the community members.
D) Description of health problems by community leaders:
While descriptions of health problems by community leaders can provide valuable context and insight, they may not always reflect the full spectrum of the community’s health needs or the individual concerns of its members. Direct input from community members about their expressed needs offers a more comprehensive and relevant understanding of the health issues that require attention.
Correct Answer is B
Explanation
A) Evaluate the teacher's ability to identify pediculosis capitis 2 months after initiation of the program:
Evaluating the teachers’ ability to identify pediculosis capitis is important for ongoing surveillance, but it does not directly measure the effectiveness of the program in reducing the prevalence of the condition. This action focuses more on teacher training rather than the program's overall impact.
B) Measure the prevalence of pediculosis capitis among the children after four months:
Measuring the prevalence of pediculosis capitis among children after the implementation of the program is the most effective way to evaluate the program's success. By comparing the prevalence before and after the program, the nurse can assess whether the interventions (educational pamphlets and regular assessments) have led to a reduction in cases.
C) Survey parents 3 weeks after pamphlets are sent home to assess their understanding of the condition:
Surveying parents about their understanding of pediculosis capitis is useful for evaluating the reach and impact of the educational component. However, it does not directly measure the effectiveness of the program in reducing the actual prevalence of pediculosis capitis among children.
D) Conduct an initial examination of each child in the school to obtain baseline data:
Conducting an initial examination provides valuable baseline data on the prevalence of pediculosis capitis before the program begins. However, this action alone does not evaluate the effectiveness of the program; it must be followed by assessments after the program’s implementation to determine if there has been a reduction in cases.
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