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.
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.
Temperature 36.8 C (98.2 F)
Heart rate 102/min
Respiratory rate 22/min
The Correct Answer is ["B","C","E","F","G"]
Rationale for Correct Choices:
- Right forearm and fingers are edematous: Swelling of the forearm and fingers can indicate a possible fracture or soft tissue injury with vascular compromise. Edema in a closed injury raises concern for compartment syndrome, especially when accompanied by other neurovascular changes.
- Ecchymotic area on outer aspect of forearm: A single bruise near the site of injury is expected after trauma and not alarming by itself. However, the chils is presenting with other multiple injuries, thus need for further assessment.
- Child reports a mild "tingling" sensation: Paresthesia can signal early nerve compression or involvement, which may progress if not addressed. Combined with swelling and coolness, this finding suggests a risk of compartment syndrome.
- Pain level of 4/10: Although moderate, a pain level of 4 in a child presenting with multiple injuries warrants further investigations.
- Multiple areas of bruising in various stages of healing: Bruising at different stages of healing raises concern for non-accidental trauma (child abuse). This pattern is inconsistent with a single fall and warrants immediate follow-up under child protection protocols.
Rationale for Incorrect Choices
- Radial pulse +2: A normal radial pulse suggests adequate arterial blood flow to the extremity. Although useful, this does not exclude compartment syndrome and is not an urgent finding on its own.
- Respirations easy and unlabored and stable vital signs: These are all normal findings that indicate no immediate respiratory, gastrointestinal, or hemodynamic distress. They do not warrant urgent intervention at this time.
- Vital signs: Temperature, blood pressure, respiratory rate and oxygen saturation are all within normal for the child’s age and support physiologic stability, hence no evidence of immediate systemic compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Encourage the client to attend a group therapy session: This action does not immediately address the restraint status. The client’s calm and cooperative behavior should prompt reassessment of restraint necessity before introducing other interventions.
B. Continue to monitor the client every 15 min: Ongoing monitoring is important but it is not the priority once the client has de-escalated. If the behavior no longer warrants restraints, the nurse should act promptly to remove them to preserve the client’s rights and dignity.
C. Remove the restraints from the client: Restraints should be discontinued as soon as the client demonstrates self-control and no longer poses a risk to themselves or others. Keeping restraints on unnecessarily can lead to psychological harm, reduced mobility, and legal/ethical violations.
D. Offer the client PRN pain medication: Offering pain medication assumes the client is experiencing discomfort, but there is no indication of pain in the scenario. Medication is not the priority when behavioral signs point to de-escalation and restraint removal is warranted.
Correct Answer is D
Explanation
Rationale:
A. Diabetes screening: Screening for diabetes is a form of secondary prevention, aimed at early identification and intervention to prevent disease progression in asymptomatic individuals.
B. Nutrition counseling: Nutrition counseling is a primary prevention strategy when used to promote health and prevent disease. It aims to reduce risk factors before illness occurs.
C. Family planning: Family planning falls under primary prevention as it involves proactive measures to prevent unintended pregnancies and support reproductive health.
D. Physical therapy: Physical therapy is a tertiary prevention measure focused on reducing the impact of an existing disease or injury. It helps restore function, prevent further disability, and improve quality of life in individuals with chronic or advanced conditions.
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