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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 B

Explanation

Rationale:

A. "Remove a plug from the socket by pulling the cord": Yanking the cord can damage the cord, loosen wiring, and increase the risk of sparks or electrical fire. The correct method is to grasp the plug firmly and pull it straight out to avoid strain on the wire connections.

B. "Use three-pronged grounded plugs": Three-pronged plugs provide a grounding mechanism that reduces the risk of electric shock and fire. Grounded outlets redirect excess electricity safely into the ground if a fault occurs, making them a key part of electrical safety.

C. "Check for a tingling sensation around the cord": A tingling sensation can indicate an electrical short or exposed wiring, which is a serious safety hazard. While it’s important to report and stop using such cords, the focus should be on prevention before such issues arise.

D. "Cover extension cords with a rug": Covering cords with rugs can trap heat, cause insulation to wear down, and increase fire risk. Cords should be left uncovered and positioned to avoid foot traffic while maintaining ventilation to prevent overheating.

A. Make an audio recording of the adolescent's responses B. Promise not to disclose information shared during the interview C. Obtain a history from both the adolescent and their caregiver. D. Use leading questions during the interview.

Correct Answer is C

Explanation

Rationale:

A. Make an audio recording of the adolescent's responses: Audio recordings require consent and may not be legally or ethically appropriate in suspected abuse cases. Documentation should be written, factual, and follow institutional policies and mandatory reporting laws.

B. Promise not to disclose information shared during the interview: Nurses must never promise confidentiality in suspected abuse cases, as they are mandated reporters. All disclosures of abuse must be reported to child protective services or appropriate authorities.

C. Obtain a history from both the adolescent and their caregiver: Gathering information from both parties helps identify inconsistencies and assess the situation fully. However, this should be done separately to allow the adolescent to speak freely and without coercion.

D. Use leading questions during the interview: Leading questions can influence the adolescent’s responses and compromise the integrity of the assessment. Open-ended, nonjudgmental questions are essential to support accurate and unbiased information gathering.

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