Which of the following clients would the nurse report as a suspected abuse case?

A 10-year-old with a burn on the palm of the hand

A 6-year-old with splash burns on the front torso

A 4-year-old with circular abrasions around the wrists

A 2-year-old with a large bruise on the forehead

Answer and Explanation

The Correct Answer is C

A. A 10-year-old with a burn on the palm of the hand: This could potentially be accidental, for example, from touching a hot surface. However, while it requires further investigation, it is not as strongly indicative of abuse as the given option.
B. A 6-year-old with splash burns on the front torso: These burns could result from accidentally spilling hot liquids. Though it raises concern, it often indicates an accident rather than abuse unless accompanied by other suspicious signs.
C. A 4-year-old with circular abrasions around the wrists: This is highly suspicious of abuse because circular abrasions can indicate that the child may have been tied or restrained, which is not typical of accidents or normal play.
D. A 2-year-old with a large bruise on the forehead: This type of injury is common in young children who are prone to falls and bumps. It might not immediately suggest abuse without additional context.

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Correct Answer is []

Explanation

Complication: Otitis Media

Anatomical Changes:

Small external ear structure: Infants born with a cleft palate often have smaller external ear structures, which can affect the drainage of fluids and increase the risk of infections.
Horizontal eustachian tubes: Eustachian tubes in individuals with cleft palate are typically more horizontal than normal, impairing the drainage of fluid from the middle ear.
Large tongue: A large tongue may obstruct the upper airway and interfere with normal swallowing and speaking functions.

Complication: Otitis Media

Due to the anatomical changes associated with cleft palate, such as horizontal eustachian tubes and impaired drainage, individuals are prone to recurrent middle ear infections (otitis media). These infections can lead to fluid accumulation behind the eardrum, which can further impair hearing and potentially lead to more serious complications if untreated.

Priority Interventions:

Ear drops (for otitis media): Ear drops containing antibiotics may be prescribed to treat bacterial infections in the middle ear, which are common in individuals with cleft palate.
- Rationale: Ear drops help to directly treat the infection in the ear canal and middle ear, reducing inflammation and preventing complications such as hearing loss or spread of infection.
Corticosteroids (for inflammation): Corticosteroids may be used to reduce inflammation in the ear canal and middle ear, particularly in cases of severe otitis media.
- Rationale: Corticosteroids help to decrease swelling and inflammation, which can improve symptoms and aid in the healing process of the ear.

A. The newborn with a heart rate of 154 beats/minute B. The newborn with a respiratory rate of 72 breaths/minute C. The newborn with a red raised capillary hemangioma on left forearm D. The newborn with whitish, hardened nodules on the gums of the mouth

Correct Answer is B

Explanation

A. The newborn with a heart rate of 154 beats/minute. This is within the normal range for a newborn, which is between 120-160 beats per minute.
B. The newborn with a respiratory rate of 72 breaths/minute. This is abnormal; the normal respiratory rate for a newborn is between 30-60 breaths per minute. A rate of 72 could indicate respiratory distress and requires prompt evaluation.

C. The newborn with a red raised capillary hemangioma on the left forearm. Capillary hemangiomas are common, benign vascular tumors that typically do not require immediate intervention.
D. The newborn with whitish, hardened nodules on the gums of the mouth. These are likely Epstein pearls, which are harmless cysts often seen in newborns and typically resolve on their own.

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Which of the following clients would the nurse report as a suspected abuse case?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Identify a complication resulting from a cleft palate, the anatomical changes that lead to the complication, and the priority interventions for care.

Correct Answer is []

Explanation

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Correct Answer is B

Explanation

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