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A nurse in a pediatric unit is assisting with providing care for multiple children. Which of the following physical findings and parental reports should cause the nurse to suspect child maltreatment?
- A. A toddler has a spiral fracture, and the parent reports a fall from a swing.
- B. A preschooler has bruises on the shins, and the parent reports a collision with furniture.
- C. An adolescent has a head injury, and the parent reports a fall from a bike.
- D. A school-age child has a black eye, and the parent reports a fight with a classmate.
Correct Answer: A
Rationale: Spiral fractures in toddlers are concerning for abuse, as they often result from twisting forces not typical in a fall from a swing. Bruises on shins, head injuries from biking, and a black eye from a fight are more consistent with common childhood injuries.
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A nurse is preparing to perform a heel stick on an infant. Which of the following actions should the nurse take?
- A. Use an automated lancet device to puncture the heel.
- B. Apply limb restraints to the infant.
- C. Puncture the heel at the inner aspect of the heel.
- D. Cleanse the area with povidone iodine.
Correct Answer: A
Rationale: An automated lancet device ensures a controlled puncture, minimizing discomfort. Restraints are unnecessary, the inner heel is not the correct site, and povidone iodine is not typically used for heel sticks.
A nurse is assisting with providing care for an adolescent client who has neuropathic pain. Which of the following medications should the nurse anticipate administering?
- A. Oxycodone
- B. Gabapentin
- C. Acetaminophen
- D. Duloxetine
Correct Answer: B
Rationale: Gabapentin is effective for neuropathic pain by modulating nerve activity. Oxycodone and acetaminophen are less specific, and duloxetine is not first-line for adolescents.
A nurse is collecting data from a 7-year-old child. Which of the following findings indicates a developmental delay?
- A. Unable to verbalize the date
- B. Unable to count backwards from 20 to 1
- C. Unable to make change out of a quarter
- D. Unable to tell the difference between right and left
Correct Answer: D
Rationale: Difficulty distinguishing right from left by age 7 suggests a developmental delay, as this milestone is typically achieved earlier. Other options reflect advanced skills not expected at this age.
A nurse is collecting data from an 8-month-old infant. Which of the following findings indicates expected growth and development?
- A. Inability to hold a bottle
- B. Uses palmar grasp
- C. Sits unsupported
- D. Forces tongue outward when it is touched
Correct Answer: C
Rationale: Sitting unsupported by 8 months is expected. Bottle holding occurs earlier, palmar grasp fades by this age, and tongue thrust typically resolves by 6 months.
A nurse is planning to reinforce teaching about head injuries with a group of parents of school-age children. The nurse should instruct the parents to monitor for and report which of the following manifestations?
- A. Insomnia
- B. Irritability
- C. Diarrhea
- D. Hypothermia
Correct Answer: B
Rationale: Irritability may signal increased intracranial pressure post-head injury, requiring prompt reporting. Insomnia, diarrhea, and hypothermia are less directly related.