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 ["C","D"]
Explanation
Rationale for Correct Choices
• Intravenous antibiotic: The client shows classic signs of postpartum endometritis, including fever, uterine tenderness, boggy fundus, and foul-smelling lochia. IV antibiotics are the primary treatment to target the uterine infection and prevent progression or sepsis.
• Increase in daily fluid intake: Adequate hydration supports circulation, helps maintain uterine tone, and assists in reducing the risk of complications such as hypotension or dehydration from infection. Fluids also support antibiotic therapy by promoting renal clearance and overall recovery.
Rationale for Incorrect Choices
• Kleihauer-Betke test: This test identifies fetal-to-maternal hemorrhage, which is not indicated here because the client’s hemoglobin is stable and there is no evidence of significant postpartum hemorrhage.
• Tocolytic medication: Tocolytics are used to suppress preterm labor, which is irrelevant for this postpartum client whose uterus has already delivered the fetus.
• Intrauterine tamponade balloon: This intervention is used for severe postpartum hemorrhage to mechanically control bleeding. The client’s bleeding is moderate and the uterus is firm after massage, so this is not indicated at this time.
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