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NCLEX-PN

Category - Psychosocial Integrity

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The nurse is assessing a 3-year-old boy with an admitting diagnosis of acute bronchiolitis. Which of the following findings during assessment should cause the nurse to suspect abuse?

Superficial scrapes on the lower legs
Dirty, matted hair
Bruises in various colors on the buttocks
Dark red lesion on the left thigh that does not blanch with pressure

Explanation

Answer: C - Bruises in various colors or stages of healing found in protected areas should cause the nurse to suspect abuse. Superficial scrapes on the lower legs are usually seen in active children. A dark lesion on the thigh is indicative of a port-wine stain. Dirty, matted hair is suggestive of neglect, not abuse.

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