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A nurse is caring for a 9-year-old child at a clinic.

Exhibits

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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E","F"]

Explanation

Rationale:

A. Blood pressure: Orthostatic hypotension is evident from the drop in systolic and diastolic pressure when standing, indicating fluid and electrolyte imbalance. This may reflect volume depletion due to purging and requires monitoring to prevent fainting or falls.

B. Syncope: The client reports repeated fainting episodes, a red flag when paired with orthostatic hypotension and electrolyte disturbances. This suggests unstable cardiovascular status and raises the risk of injury or sudden cardiac events.

C. ECG: Sinus tachycardia with premature ventricular contractions indicates cardiac irritability likely due to electrolyte imbalance, especially hypokalemia. Continuous cardiac monitoring and correction of abnormalities are needed.

D. Albumin: An albumin level of 2.6 g/dL indicates significant malnutrition and protein deficiency, compromising immune function and wound healing. This also suggests a chronic issue requiring dietetic intervention and nutritional rehabilitation.

E. Potassium: Potassium at 3.0 mEq/L is dangerously low and a known contributor to cardiac arrhythmias and muscle weakness. Replenishment and close monitoring are critical to avoid complications such as cardiac arrest.

F. Sodium: Although sodium is only slightly low at 134 mEq/L, in the context of purging and poor intake, this could indicate dilutional hyponatremia. It increases seizure risk and needs assessment of fluid status and intake behaviors.

A. Place the client upright on a donut-shaped cushion. B. Teach the client to shift his weight every 15 min while sitting. C. Assess pressure points every 24 hr. D. Turn and reposition the client every 3 hr while in bed.

Correct Answer is B

Explanation

Rationale:

A. Place the client upright on a donut-shaped cushion: Donut-shaped cushions are not recommended because they create uneven pressure distribution, which can worsen ischemia around pressure points rather than relieve it, potentially delaying healing.

B. Teach the client to shift his weight every 15 min while sitting: Frequent weight shifting relieves pressure on the ischial area and promotes circulation, helping to prevent progression of a stage 1 pressure injury. This intervention supports client independence and tissue integrity.

C. Assess pressure points every 24 hr: Pressure points should be assessed more frequently than once daily, especially in high-risk clients. Routine skin assessments at least once per shift are critical for early detection of pressure injury progression.

D. Turn and reposition the client every 3 hr while in bed: The standard recommendation is to reposition immobile clients at least every 2 hours in bed to redistribute pressure and reduce the risk of further skin breakdown. Extending intervals increases risk of injury.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in an emergency department (ED).Exhibits Which of the following findings in the client's medical record requires follow-up by the nurse? Select all that apply

Correct Answer is ["A","B","C","D","E","F"]

Explanation

A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?

Correct Answer is B

Explanation

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