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 B
Explanation
Rationale:
A. "You should expect your blisters to last up to three weeks.": Herpes zoster lesions typically last 7 to 10 days, with crusting and healing often occurring within 2 weeks. While some cases may extend slightly longer, stating "up to three weeks" may overgeneralize and mislead.
B. "Antiviral medications are most effective if taken within the first 72 hours of symptoms.": Antiviral drugs like acyclovir or valacyclovir are most effective when initiated within 72 hours of symptom onset. Early treatment reduces severity, duration, and the risk of complications such as postherpetic neuralgia.
C. "People who have had chicken pox are at a decreased risk for herpes zoster.": Herpes zoster occurs due to reactivation of the varicella-zoster virus, which remains dormant after chickenpox. Therefore, individuals who have had chickenpox are actually at increased risk.
D. "Severe pain after the blisters are gone is less common in older adults.": Older adults are more likely to experience postherpetic neuralgia, a complication involving persistent nerve pain after lesions resolve. The risk and severity of this pain increase with age, not decrease.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
Rationale for Correct Choices:
- Evaluating the fetal heart rate tracing: The client’s report of decreased fetal movement and severe hypertension raises concern for fetal compromise. Immediate fetal assessment ensures the fetus is tolerating the intrauterine environment, especially before administering medications like magnesium sulfate.
- Administering magnesium sulfate IV: This is prescribed to prevent eclampsia, given the client’s severely elevated BP, hyperreflexia, and proteinuria. After confirming fetal status, seizure prophylaxis should be initiated without delay.
Rationale for Incorrect Choices:
- Administering acetaminophen PO: Although ordered for headache, the symptom is a manifestation of severe preeclampsia. Treating it symptomatically without addressing its cause could delay necessary critical interventions.
- Obtaining a 24-hour urine collection: Useful for confirming the extent of proteinuria, but not immediately necessary for clinical decision-making given existing positive findings.
- Inserting an indwelling urinary catheter: This supports fluid monitoring during magnesium therapy, but fetal assessment and seizure prevention take precedence.
- Administering betamethasone IM: Important for fetal lung development in preterm pregnancies, but it is not the immediate priority when there is a high risk for seizure or fetal distress.
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