A nurse is caring for a 9-year-old child at a clinic.
The nurse reviews the assessment findings.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
Assessment
Respirations easy and unlabored. Abdomen non-distended. Right forearm and fingers are edematous. Ecchymotic area noted on outer aspect of the forearm. Radial pulse +2. Fingers slightly cool to touch. Child can move fingers and reports a mild "tingling" sensation. Child verbalizes a pain level of 4 on a scale of 0 to 10. Multiple areas of bruising are noted on lower extremities in various stages of healing.
Vital Signs
Temperature 36.8° C (98.2° F)
Heart rate 102/min Respiratory rate 22/min
BP 100/60 mm Hg
Oxygen saturation 98% on room air
Respirations easy and unlabored
Right forearm and fingers are edematous
Ecchymotic area noted on outer aspect of the forearm
Radial pulse +2
Fingers slightly cool to touch
mild "tingling" sensation
Child verbalizes a pain level of 4 on a scale of 0 to 10
Multiple areas of bruising are noted on lower extremities in various stages of healing
Oxygen saturation 98% on room air
The Correct Answer is ["B","C","E","F","H"]
Assessment
Respirations easy and unlabored. Abdomen non-distended. Right forearm and fingers are edematous. Ecchymotic area noted on outer aspect of the forearm. Radial pulse +2. Fingers slightly cool to touch. Child can move fingers and reports a mild "tingling" sensation. Child verbalizes a pain level of 4 on a scale of 0 to 10. Multiple areas of bruising are noted on lower extremities in various stages of healing.
Vital Signs
Temperature 36.8° C (98.2° F)
Heart rate 102/min
Respiratory rate 22/min
BP 100/60 mm Hg
Oxygen saturation 98% on room air
Rationale:
Edema in the right forearm and fingers: The edema, particularly in the right forearm, may indicate a possible fracture or soft tissue injury. This requires immediate follow-up, including further assessment, potential imaging (e.g., X-ray), and intervention to rule out bone fractures, compartment syndrome, or significant tissue damage.
Fingers slightly cool to touch: This could indicate compromised circulation to the fingers, potentially due to swelling or a more serious injury like a fracture causing compression or vascular injury. Immediate follow-up is necessary to assess for any signs of impaired circulation, which could require urgent medical intervention.
Mild "tingling" sensation in the fingers: The tingling sensation might indicate nerve involvement or compression, which could be related to a fracture or soft tissue injury. Immediate follow-up is needed to assess for nerve damage or compartment syndrome, both of which require timely management to prevent long-term damage.
Multiple areas of bruising in various stages of healing: While this finding does not require immediate follow-up in the context of the current injury, it could raise concerns about possible underlying issues such as bleeding disorders or abuse. Although not an immediate concern, this warrants further investigation in the longer term.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ensure that the transfusion is completed within 6 hr: Incorrect. Blood transfusions should be completed within 4 hours to reduce the risk of bacterial contamination.
B. Obtain venous access using a 22-gauge needle: Incorrect. A larger gauge (18-20) is preferred to prevent hemolysis and allow for faster administration.
C. Store the unit of blood at room temperature for 1 hr prior to the infusion: Incorrect. Blood should remain refrigerated until it is ready to be transfused, and it should be started within 30 minutes of removal from refrigeration.
D. Use a solution of 0.9% sodium chloride to flush the transfusion tubing: 0.9% sodium chloride is the only compatible solution with blood products to prevent hemolysis.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Daily weights: This task can be delegated to ensure consistent monitoring of the client's weight, which is crucial for assessing nutritional status and progress.
Observing meals: The nurse should focus on observing meals to ensure the client is eating properly and not engaging in behaviors such as pocketing food or spitting it out, which are common in clients with eating disorders.
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