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) Provide dorm teaching sessions about the need to finish prescribed antibiotic doses:
While educating about antibiotic adherence is important, it is not specifically targeted to meningococcal meningitis. This intervention is more relevant to managing infections rather than preventing meningococcal meningitis, which is primarily preventable through vaccination.
B) Encourage incoming freshmen to obtain the meningococcal polysaccharide vaccine prior to dorm living:
Meningococcal meningitis is a significant risk in college environments due to close living conditions. The meningococcal polysaccharide vaccine is effective in preventing the disease. Encouraging incoming freshmen to receive this vaccine before starting dorm life directly addresses the prevention of meningococcal meningitis and is the most effective measure for reducing incidence in this high-risk population.
C) Require documentation from incoming freshmen that Haemophilus influenza type b (Hib) vaccinations are current:
While Hib vaccinations are important for preventing certain bacterial infections, they are not specifically related to meningococcal meningitis. The Hib vaccine is not a primary prevention method for meningococcal disease, making this measure less relevant for addressing meningococcal meningitis.
D) Develop a clinic protocol for the prophylactic use of isoniazid for positive reactors:
Isoniazid is used for tuberculosis prophylaxis, not for preventing meningococcal meningitis. Developing a protocol for isoniazid would not impact the incidence of meningococcal meningitis and is therefore not relevant to this particular prevention goal.
Correct Answer is D
Explanation
A) The Centers for Disease Control and Prevention (CDC) has identified this problem as a variable in morbidity:
While the CDC provides valuable data and insights on various health issues, it may not directly frame "access to health services" as a key reason for addressing the issue in the broader context of health improvement strategies. The focus here is on the broader, more comprehensive goals rather than specific CDC findings.
B) The Community Health Improvement Process is used for issues in high-risk populations:
The Community Health Improvement Process is a method used to address health issues, but this statement does not directly explain why improving access to health services is crucial. It focuses more on the process rather than the rationale behind improving access.
C) The Institute of Medicine includes "access" as one of its priority recommendations:
The Institute of Medicine (now the National Academy of Medicine) has indeed highlighted the importance of access to health services. However, the most compelling reason for emphasizing access is its inclusion in national health goals, which underscores its broad importance.
D) The committee for "Healthy People 2030" has identified "access" as a national goal:
This statement provides the best response because it highlights that improving access to health services is a national health goal outlined in "Healthy People 2030." This demonstrates the significant importance placed on access to health services at a national level and aligns with broader public health objectives, making it a strong justification for addressing the issue in the workshop.
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