The nurse is examining a 3-year-old child. Which bruise, if found, would be of most concern?
Bruise on the elbow
Bruise on the forehead
Bruising on the abdomen
Bruise on the lower leg
The Correct Answer is C
Choice A reason: Bruises on the elbow are common in active children due to play or minor falls. They are typically not concerning unless accompanied by other suspicious signs. Abdominal bruising, however, is less common and may indicate trauma or abuse, making this less concerning.
Choice B reason: Forehead bruises are frequent in toddlers learning to walk, often from bumping into objects. While concerning if severe, they are less alarming than abdominal bruising, which is less typical and may suggest internal injury or abuse, so this is not the most concerning.
Choice C reason: Abdominal bruising in a 3-year-old is highly concerning, as it is uncommon in normal play and may indicate significant trauma, abuse, or internal injury. This location raises red flags for non-accidental injury, requiring urgent investigation, making it the most concerning bruise.
Choice D reason: Lower leg bruises are common in active children from running or minor injuries. They are less concerning than abdominal bruising, which is atypical and may signal serious trauma or abuse, so this is not the most concerning finding in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Facilitation involves encouraging elaboration, like nodding or saying “go on,” to keep the patient talking. The question “What brings you to the clinic today?” seeks a broad response, not just continuation, making this incorrect.
Choice B reason: Direct questions seek specific answers, like “Do you have pain?” The stated question allows a broad, narrative response, not a targeted one, making it an open-ended technique rather than a direct one.
Choice C reason: An open-ended question, like “What brings you to the clinic today?” invites the patient to provide a detailed, narrative response, allowing exploration of their concerns without limiting answers, making this the correct communication technique.
Choice D reason: Reflection restates the patient’s words to clarify or validate, like “You feel tired?” The question posed seeks new information, not a restatement, making it an open-ended technique, not reflection.
Correct Answer is B
Explanation
Choice A reason: A complete physical exam is comprehensive but not specific to initial nutritional screening. Height and weight history provide BMI, a quick nutritional indicator, so this is not the first assessment.
Choice B reason: Height and weight history are critical for initial nutritional screening, enabling BMI calculation to assess undernutrition or obesity. This is a standard, quick method, making it the correct first step.
Choice C reason: Calorie counting is detailed and time-consuming, unsuitable for initial screening. Height and weight offer a rapid baseline for nutritional status, so this is incorrect for the first step.
Choice D reason: Leg circumference may assess muscle mass but is not standard for initial nutritional screening. Height and weight are primary for BMI, so this is incorrect for the initial assessment.
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