1.
A nurse is caring for a child who supposedly had an accident at home. Which statement by the parents indicates the possibility of cild abuse?
Correct Answer
C. Mom "She fell off a swing"
Dad "She fell off the bed"
Explanation
Differing of how an accident occurred is a possible indication of child abuse. When parents have conflicting stories or the child has a different story then the parents, the nurse should investigate for possible abuse. The other statements should be investigated as well but they may be innocent statements.
2.
Which child appears to have been abused?
Correct Answer
C. A 3 year old who acts withdrawn and has bruises on his back
Explanation
3 year olds are typically social, not withdrawn. Bruises on the back should also be investigated. 2 year olds commonly fall and bruise their shins; its also normal for them to be afraid and avoid eye contact with nurses. 10 year olds are commonly injured during play.
3.
A couple has a 2 year old with Hurler's syndrome. When planning their next pregnancy, the couple should undergo ...
Correct Answer
A. Genetic counseling.
Explanation
Hurler's syndrome is an inherited autosomal recessive disorder. Genetic counseling should be offered. TORCH = toxoplasmosis, rubella, cytomegalovirus and herpes simplex .. aka not a screening tool for Hurler's
4.
A 13 year old with cystic fibrosis is experiencing increasing SOB, cough and sputum production, fatigue and weight loss. He's having trouble taking care of himself without exhaustion. Which approach is most appropriate when setting goals for this adolescent?
Correct Answer
D. Agree on mutual goals to increase the adolescent's sense of control in this situation.
Explanation
Teens with a long-term fatal illness need to be granted as much control as possible. Agreeing on mutual goals fosters the adolescent's sense of control and demonstrates respect for his autonomy. Letting the adolescent set goals completely on his own isn't realistic because he may not fully comprehend all of the medical aspects of his condition. Placing the physician or nurse completely in charge go goal-setting violates the adolescents need to establish a sense of control
5.
A 2 year old boy is brought to the clinic with an upper respiratory infection. During the assessment, the nurse notes some bruising on the arms, legs and trunk. Which findings should prompt the nurse to evaluate for suspected child abuse? Select all that apply.
Correct Answer(s)
B. Welts/bruises in various stages of healing on the trunk
E. Circular, symmetrical burns on the lower legs
F. A parent who is hypercritical of the child and pushes the frightened child away
Explanation
Injuries at various stages of healing in protected or padded areas can be signs of inflicted trauma, leading the nurse to suspect abuse. Burns that are bilateral as well as symmetrical and regular (like a cigarette) are typical of abuse. When a child is burned accidentally, the burns form an erratic pattern and are usually irregular and asymmetrical. Pushing away the child and being hypercritical are typical behaviors of abusive parents.Superficial scrapes and bruises on the lower extremities are normal in a healthy child. A deep blue-black macular patch on the buttocks is more consistent with a Mongolian spot rather than a traumatic injury that would suggest abuse.
6.
A nurse is teaching a school class about malnutrition. She tells them that marasmus is ...
Correct Answer
A. General malnutrition of calories and protein.
Explanation
Commonly happens in developing countries during times of drought, especially where ADULTS EAT BEFORE CHILDREN. Whatever food remains is commonly insufficient in quality and quantity for children. Kwashiorkor (NOT MARASMUS) is a protein deficiency in which calorie supply is adequate, fat metabolism is impaired and mineral deficiency is common. Iron deficiency is common with anemia; calcium deficiency causes rickets; zinc deficiency causes skin lesions and decreased taste.
7.
When conducting a home visit, a nurse notes that the mother of a toddler has cleaning material stored beneath the kitchen and bathroom sinks. Medicines are on a tray on the dining room buffet. The mother explains that the medicines are out so family members can remember to take them. Which nursing diagnosis is most appropriate?
Correct Answer
C. Risk for injury related to lack of awareness of environmental hazards
Explanation
The lack of awareness of the dangers of the cleaning materials and medicines puts the toddler at risk for injury. Theres no evidence that the child has deficient knowledge or that compromised family coping processes or impaired parenting exists.
8.
An 8 year old child develops juvenile rheumatoid arthritis. Which factor most influences the way chronic illness or disability impacts a child?
Correct Answer
B. Age of onset
Explanation
The impact of a chronic illness or disability is influenced by the age of onset and the child's developmental level. Chronic illness affects children of all ages but the developmental aspects of each age-group dictate particular stresses and risks for each child. The parents reaction may not be evident, especially to a young child. The age of the child's siblings has less of an impact on the child than it does on the parents.
9.
A 3 year old is admitted with respiratory syncytial virus infection. The nurse obtains a history of ritualistic behavior for the child to ...
Correct Answer
A. Allow the child's routine to be continued.
Explanation
The nurse should obtain a history that includes the child's ritualistic behavior (like reading before going to bed) so that the child's typical routine can be continued. This decreases fear of the hospital. It doesn't make the parents feel more in control or give the nurse greater control of the child's behavior. It also doesn't decrease the child's sense of separation from his parents.