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Which observation is most likely to cause the nurse to consider the possibility of child abuse when a mother says that her young child fell down the basement stairs?
- A. Red, green, and yellow bruises on his body.
- B. Bruises are dispersed on his head, arms, and legs.
- C. A broken arm last year, and the child being described as accident-prone.
- D. The mother is very anxious for her son to get medical attention.
Correct Answer: A
Rationale: Multiple bruise colors indicate injuries at different healing stages, suggesting possible abuse rather than a single incident.
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What intervention is appropriate for a nurse assessing a preadolescent child for scoliosis?
- A. Ask the child to bend forward at the waist and observe the child's back for asymmetry.
- B. Observe the gait while the child is walking forward heel to toe.
- C. Have the child flex the knees and look for uneven knee height.
- D. Look at the child's shoulders and hips while fully clothed.
Correct Answer: A
Rationale: Bending forward at the waist allows the nurse to observe back asymmetry, a key sign of 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 does the nurse explain as the cause of this spinal curvature defect?
- A. Juvenile rheumatoid arthritis
- B. Poor posture
- C. Heredity
- D. Myelomeningocele
Correct Answer: B
Rationale: Functional scoliosis is typically caused by poor posture and is not a structural spinal disease.
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.
Which assessment performed by a nursing student performing a neurovascular check alerts the instructor that further education is necessary?
- A. Pulses
- B. Capillary refill
- C. Movement
- D. Pupils
Correct Answer: D
Rationale: Pupil assessment is part of a neurological check, not a neurovascular check, which includes pulses, capillary refill, and movement.