NR 328
(EDAPT WEEK 8)
Child Abuse Case Study
Pediatric Nursing
,Child Abuse Case Study
The nurse is caring for a 2-year-old child in the emergency department
(ED). Review the electronic health record (EHR) before answering each
question.
Question
Based on the nurse’s documentation, select the 4 findings that
require immediate attention.
“Strange behavioral things”
Vomiting and diarrhea with up to 10 loose green stools
Last void over 12 hours ago
Becoming more lethargic
Consider Maslow’s hierarchy of needs. Which findings are most
concerning? The physiological needs take priority over the psychosocial
needs.
The following items need immediate follow-up by the nurse:
Vomiting, diarrhea, and not voiding for 12 hours are of the biggest
concern as they will lead to a fluid volume deficit and dehydration.
Lethargy and “strange behavioral things” (or potential altered mental
status) are concerning and need to be investigated further; they may
be a result of the dehydration, trauma, or neglect.
Question
For each client finding below, click to specify if the finding is consistent with the disease
process. Select only the most likely disease process for each finding.
Dehydration Gastroenteritis Physical Abuse
Bruising x
, Dehydration Gastroenteritis Physical Abuse
Change in stool pattern x
Dry mucous membranes x
No tears when crying x
Aggression x
Sunken eyes x
Different disease processes can have overlapping symptoms. In some
cases, like with gastroenteritis, the client may also be dehydrated. Here is
a list of some common clinical manifestations (cues) for each of these
disease processes.
Dehydration
weight loss
capillary refill greater than 4 seconds
tachycardia
orthostatic blood pressure
extreme thirst
very dry mucous membranes
tented skin
hyperpnea
no tearing
sunken eyeballs
oliguria or anuria
sunken anterior fontanel in infants
Gastroenteritis
fatigue
malaise
change in behavior
change in stool pattern
(EDAPT WEEK 8)
Child Abuse Case Study
Pediatric Nursing
,Child Abuse Case Study
The nurse is caring for a 2-year-old child in the emergency department
(ED). Review the electronic health record (EHR) before answering each
question.
Question
Based on the nurse’s documentation, select the 4 findings that
require immediate attention.
“Strange behavioral things”
Vomiting and diarrhea with up to 10 loose green stools
Last void over 12 hours ago
Becoming more lethargic
Consider Maslow’s hierarchy of needs. Which findings are most
concerning? The physiological needs take priority over the psychosocial
needs.
The following items need immediate follow-up by the nurse:
Vomiting, diarrhea, and not voiding for 12 hours are of the biggest
concern as they will lead to a fluid volume deficit and dehydration.
Lethargy and “strange behavioral things” (or potential altered mental
status) are concerning and need to be investigated further; they may
be a result of the dehydration, trauma, or neglect.
Question
For each client finding below, click to specify if the finding is consistent with the disease
process. Select only the most likely disease process for each finding.
Dehydration Gastroenteritis Physical Abuse
Bruising x
, Dehydration Gastroenteritis Physical Abuse
Change in stool pattern x
Dry mucous membranes x
No tears when crying x
Aggression x
Sunken eyes x
Different disease processes can have overlapping symptoms. In some
cases, like with gastroenteritis, the client may also be dehydrated. Here is
a list of some common clinical manifestations (cues) for each of these
disease processes.
Dehydration
weight loss
capillary refill greater than 4 seconds
tachycardia
orthostatic blood pressure
extreme thirst
very dry mucous membranes
tented skin
hyperpnea
no tearing
sunken eyeballs
oliguria or anuria
sunken anterior fontanel in infants
Gastroenteritis
fatigue
malaise
change in behavior
change in stool pattern
