The practical nurse (PN) is assisting with screening examinations at a community clinic where a toddler is brought by a parent for scheduled vaccines. The toddler clings to the caregiver and cowers when approached. Which assessment warrants immediate intervention by the PN?
Several dime-sized circular burns on the back.
Refusal to answer simple questions.
One-inch laceration across center of forehead.
Small bruises on the lower extremities.
The Correct Answer is A
A. Several dime-sized circular burns on the back:
Highly suspicious for abuse; requires immediate intervention and reporting.
B. Refusal to answer simple questions:
May be fear or shyness; not as urgent as evidence of abuse.
C. One-inch laceration across center of forehead:
May occur with typical toddler activity; assess but not as high-priority for abuse suspicion.
D. Small bruises on the lower extremities:
Common in active toddlers; less suspicious for abuse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Infusion pump and IV site: Necessary but not priority for safety during epidural initiation.
B. Level of pain sensation: Important for effectiveness but not as urgent as monitoring for hypotension.
C. Maternal blood pressure (BP): Epidural anesthesia can cause vasodilation and maternal hypotension, which can compromise fetal oxygenation.
D. Variability of fetal heart rate: Important but affected indirectly by maternal BP; BP is assessed first.
Correct Answer is D
Explanation
A. Redness of the cheek under the cannula: Indicates skin irritation, but can usually be managed locally; not the most urgent.
B. Dry, cracked mucous membranes: Suggests dryness from oxygen but not immediately life-threatening.
C. Encrustations on both of the eyelids: Could indicate infection or poor hygiene but less urgent than neurological changes.
D. Drooping of the right side of the mouth: This could indicate a new-onset stroke (facial droop), which is a neurological emergency requiring immediate reporting.
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