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 {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Rationale for Correct Answers:
1. Condition: Mastitis
Mastitis is an infection of the breast tissue that commonly affects breastfeeding women. It often occurs when bacteria (usually Staphylococcus aureus) enter through a cracked or damaged nipple, allowing pathogens to travel into the milk ducts. Symptoms can start with nipple pain and breast tenderness, progressing to flu-like symptoms, localized redness, and fever if untreated.
2. Evidence: Cracked nipple
The client's report of nipple discomfort throughout feeding and visible crack noted on the left nipple are red flags for potential bacterial entry, placing her at high risk for mastitis. Cracked nipples are common in breastfeeding, especially when there is poor latch or prolonged feeding.
Rationale for Incorrect Options:
Endometritis: This is an infection of the uterine lining. However, this client is 2 weeks postpartum, denies abdominal pain, and has normal lochial progression (whitish-yellow discharge = lochia alba). Her uterus is no longer palpable, indicating appropriate involution. No signs of fever, foul-smelling discharge, or uterine tenderness are noted.
Perineal hematoma: This would present with significant perineal pain, swelling, and possibly bluish discoloration. This client reports only mild perineal discomfort (2/10), likely related to normal healing from her episiotomy.
Group B streptococcus: The client tested negative for Group B Streptococcus. Moreover, GBS is not directly related to cracked nipples or mastitis.
Large for gestational age newborn: While the newborn was indeed LGA, this mainly increases the risk for perineal trauma or shoulder dystocia, not directly mastitis.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}
Explanation
Rationale:
- Instruct client to avoid foods that have been fermented or aged: This dietary restriction applies to monoamine oxidase inhibitors (MAOIs), not trazodone, which is a serotonin antagonist and reuptake inhibitor (SARI).
- Encourage client to sleep until later in the morning: Oversleeping can disrupt circadian rhythms and worsen fatigue. A consistent, balanced sleep schedule is more therapeutic.
- Advise client to notify provider if pregnant: Trazodone is a category C medication and should only be used in pregnancy if the benefits outweigh the risks. The provider must be informed if the client is or may become pregnant.
- Encourage high-calorie finger foods: The client has experienced weight loss and decreased appetite. Nutrient-dense, easy-to-eat foods can support caloric intake without requiring full meals.
- Advise client to rise slowly from sitting position: Trazodone can cause orthostatic hypotension. Educating the client to change positions slowly helps prevent dizziness and potential falls.
- Encourage naps during the day when client is tired: Daytime napping can interfere with nighttime sleep and may reduce trazodone’s effectiveness in establishing a healthy sleep pattern.
- Encourage a regular sleep-wake schedule: Trazodone is often prescribed for sleep difficulties. A consistent routine supports sleep hygiene and enhances the medication’s effectiveness.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.