Nokea
What do these finding indicate?
- A. Sexual abuse
- B. Physical abuse
- C. Physical neglect
- D. Emotional abuse
Correct Answer: C
Rationale: Disheveled appearance, being unbathed, and hungry suggest physical neglect, failing to meet the child's basic needs.
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Which nursing diagnosis takes highest priority for this child?
- A. Pain resulting from tissue trauma
- B. High risk for impaired skin integrity resulting from immobility
- C. Altered growth and development related to separation from family
- D. Altered urinary elimination related to immobility and traction
Correct Answer: A
Rationale: Pain from tissue trauma and muscle spasm is the highest priority due to its immediate impact on the child's comfort.
What instruction would the nurse provide to an adolescent who has been fitted with a Milwaukee brace?
- A. Wear the brace directly against the skin.
- B. Wear the brace over regular clothing.
- C. Wear the brace over a T-shirt 23 hours a day.
- D. Remove the brace before sleeping.
Correct Answer: C
Rationale: Wearing the Milwaukee brace over a T-shirt for 23 hours daily protects the skin while correcting scoliosis.
What nursing action will significantly decrease the risk of serious complications for a child in Bryant's traction?
- A. Neurovascular checks are done frequently.
- B. Bandages are wrapped tightly.
- C. The child is restrained from rolling over.
- D. The child's buttocks are resting on the bed.
Correct Answer: A
Rationale: Frequent neurovascular checks help detect Volkmann's ischemia, reducing the risk of circulatory complications.
What factor(s) may trigger abuse in a parent?
- A. Being abused as a child
- B. High self-esteem
- C. Substance abuse
- D. Overwhelming responsibility
- E. Knowledge deficit relative to child care
Correct Answer: A,C,D,E
Rationale: Being abused as a child, substance abuse, overwhelming responsibility, and lack of child care knowledge are triggers for parental abuse; high self-esteem is not.
What finding would the nurse assessing the neurovascular status of a child in Russell traction report immediately?
- A. Skin that's warm to the touch
- B. Capillary refill less than 3 seconds
- C. Ability to wiggle toes
- D. Bluish coloration of skin
Correct Answer: D
Rationale: Bluish skin (cyanosis) indicates circulatory impairment, requiring immediate reporting to prevent complications.