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A nurse is assisting in the care of a 6 year old child who preoperative for repair of a fractured femur.

Exhibits
For each finding click to specify whether the finding indicates no change in the child's condition or is a sign of potential worsening condition.

A.

Skin temperature

B.

Capillary refill

C.

Pedal pulse

D.

Sensation

E.

Swelling

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Findings

No changes in condition

Sign of potential worsening

 

Skin temperature

 

✓

Capillary refill

 

✓

Pedal pulse

 

✓

Sensation

 

✓

Swelling

✓

 

 

  • Skin temperature: The left toes are now cool to touch, indicating a potential worsening condition.
  • Capillary refill: Capillary refill greater than 3 seconds suggests compromised circulation, indicating a potential worsening condition.
  • Pedal pulse: A pedal pulse of 1 in the left leg indicates decreased blood flow, suggesting a potential worsening condition.
  • Sensation: The sensation of pins and needles in the left foot indicates potential nerve involvement, suggesting a potential worsening condition.
  • Swelling: The swelling of the left toes remains unchanged, indicating no change in the condition.


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Related Questions

Correct Answer is A

Explanation

A. Saying, "It is not your fault that this happened," is correct. This statement reassures the child that they are not to blame for the abuse, which is crucial in reducing feelings of guilt or self-blame. It also helps build trust between the child and the nurse.

B. Saying, "This should not have happened to you," is incorrect. While it acknowledges the wrongdoing, it does not directly reassure the child that they are not responsible for the situation.

C. Saying, "I promise I won’t tell anyone about this," is incorrect and unethical. Healthcare professionals are mandated reporters and must report suspected abuse to the appropriate authorities. Making such a promise could lead to broken trust when the nurse is required to disclose the information.

D. Saying, "You should have told someone about this sooner," is incorrect. This statement may make the child feel guilty or ashamed for not speaking up earlier, which can discourage further disclosure and hinder emotional healing.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

Findings

No changes in condition

Sign of potential worsening

Skin temperature

✓

Capillary refill

✓

Pedal pulse

✓

Sensation

✓

Swelling

✓

  • Skin temperature: The left toes are now cool to touch, indicating a potential worsening condition.
  • Capillary refill: Capillary refill greater than 3 seconds suggests compromised circulation, indicating a potential worsening condition.
  • Pedal pulse: A pedal pulse of 1 in the left leg indicates decreased blood flow, suggesting a potential worsening condition.
  • Sensation: The sensation of pins and needles in the left foot indicates potential nerve involvement, suggesting a potential worsening condition.
  • Swelling: The swelling of the left toes remains unchanged, indicating no change in the condition.

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