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. The Senior Citizen Center: The Senior Citizen Center is a resource that offers a variety of services to older adults, including social activities, meal programs, and support services. Given the client's recent weight loss and living alone, referring them to the Senior Citizen Center could provide access to resources and support that might help address potential underlying issues such as social isolation or inadequate nutrition.

B. The Social Security Administration office: The Social Security Administration (SSA) office handles matters related to social security benefits, such as retirement, disability, and survivor benefits. While important, it does not provide the kind of immediate support and services related to the client's weight loss and daily needs.

C. The Adult Day Care Center: The Adult Day Care Center provides daytime care and activities for older adults who need supervision or assistance during the day. Since the client drives and lives alone, this may not be the most appropriate referral unless there are additional concerns about daily supervision or care needs.

D. The Women, Infant, and Children (WIC) office: The WIC program provides nutrition assistance to low-income pregnant women, new mothers, and young children. It is not relevant for older adults, so this would not be the appropriate agency for addressing the client’s needs related to weight loss.

A. Emphasize that using safe sex practices removes the risk of sexually transmitted Infections (STIs) B. Clarify that all sexually transmitted infections (STIs) are transmitted through sexual intercourse. C. Discuss that partners without similar symptoms may not be infected. D. Instruct the client on the importance of notifying sexual partners.

Correct Answer is D

Explanation

A. Emphasize that using safe sex practices removes the risk of sexually transmitted infections (STIs):
While safe sex practices significantly reduce the risk of STIs, they do not eliminate it entirely. It is important to communicate that while the risk is reduced, it is not completely absent.

B. Clarify that all sexually transmitted infections (STIs) are transmitted through sexual intercourse:
This statement is not entirely accurate. While most STIs are transmitted through sexual intercourse, some can also be spread through other means, such as blood contact or from mother to child during childbirth.

C. Discuss that partners without similar symptoms may not be infected:
STIs like gonorrhea can be asymptomatic in many individuals, meaning they can still transmit the infection to others even if they do not show symptoms. This response could be misleading, as it may cause the client to mistakenly believe that partners without symptoms are not at risk.

D. Instruct the client on the importance of notifying sexual partners:
It is crucial for the client to notify all sexual partners about the infection so that they can be tested and treated if necessary. This helps prevent the further spread of the infection and ensures that partners receive appropriate care.

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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

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Correct Answer is A

Explanation

The nurse is caring for a client with gonorrhea. The client reports having sex with multiple partners. Which response should the nurse provide?

Correct Answer is D

Explanation

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