A nurse is caring for a 9-year-old child at a clinic.
The nurse should determine that the assessment findings are consistent with which of the following conditions?
For each potential condition, click to specify if the assessment findings are consistent with a sprain, a fracture, or a dislocation. Each finding may support more than 1 condition.
Edema
Sensation
Ecchymosis
Pain level
The Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B,C"}}
Rationale:
• Edema: Swelling occurs in sprains, fractures, and dislocations due to tissue injury, inflammation, and bleeding into the surrounding area. It is a non-specific sign of trauma but indicates soft tissue or bony involvement.
• Sensation (tingling): Altered sensation is more commonly associated with fractures and dislocations because of nerve compression or injury near the affected bone or joint. Sprains typically do not involve neurological changes unless severe.
• Ecchymosis: Bruising occurs in sprains, fractures, and dislocations due to vascular injury from trauma. It helps localize the injury but cannot differentiate between soft tissue and bone involvement.
• Pain level (4/10): Pain is present in all three conditions. The intensity may vary depending on the severity of injury, but mild to moderate pain is expected in sprains, fractures, and dislocations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Calculation:
- Identify the client's weight in kilograms (kg) and height in meters (m).
Weight = 75 kg
Height = 1.8 m
- Calculate the square of the height in meters (m squared).
Height squared = 1.8 m x 1.8 m
= 3.24 m squared.
- Calculate the BMI.
BMI = Weight (kg) / Height (m squared)
= 75 kg / 3.24 m squared
= 23.148
- Round the answer to the nearest tenth.
= 23.1
Correct Answer is A
Explanation
Rationale:
A. Pudendal block: A pudendal block is a safe and effective pain management option for a client who is fully dilated and pushing during the second stage of labor. It provides local anesthesia to the perineal area, reducing pain associated with delivery and episiotomy without affecting uterine contractions or the fetus.
B. Naloxone hydrochloride: Naloxone is not a pain medication; it is an opioid antagonist used to reverse the effects of opioid-induced respiratory depression. Administering naloxone at this stage would not relieve labor pain and is inappropriate unless needed for opioid reversal.
C. Spinal anesthesia: Spinal anesthesia is typically administered before the second stage of labor, such as for a cesarean birth. Administering it when the client is fully dilated and pushing could delay delivery and increase the risk of complications from sudden hemodynamic changes.
D. Butorphanol tartrate: Butorphanol is an opioid agonist-antagonist analgesic that can cause respiratory depression in the newborn if given too close to delivery. Since the client is already in the pushing stage, administering this medication poses a risk to the fetus and is therefore unsafe.
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