A nurse is caring for a 9-year-old child at a clinic.
Vital Signs.
1000:. Temperature 36.8°C (98.2 °F). Heart rate 102/min.
Respiratory rate 22/min.
BP 100/60 mm Hg. Oxygen saturation is 98% on room air.
Nurses' Notes.
1000:.The child has been brought to the clinic by their parent due to a. report of right arm pain.
The parent states that several hours.
ago the child tripped and fell onto the sidewalk while playing.
outside.
The child states, "I was running when we were playing,and I tripped over a curb." The child is supporting their arm across.
their body.
Assessment.
1000:The child is alert and appears developmentally appropriate for their.
age and well nourished.
Respirations are easy and unlabored.
Abdomen nondistended.
The right forearm and fingers are edematous.
Ecchymotic area.
noted on the outer aspect of the forearm.
Radial pulse +2. Fingers.
slightly cool to the touch.
A child can move fingers and reports a mild.
"tingling" sensation.
The child verbalizes a pain level of 4 on a scale.
of 0 to 10. Abrasion noted on the right knee.
No active bleeding.
Multiple areas of bruising were noted on the lower extremities in various.
stages of healing.
The nurse should determine that the assessment findings are consistent with.
which of the following conditions? For each potential condition, click to specify if the assessment findings are.
consistent with a sprain, a fracture, or dislocation.
Each finding may support this.
more than 1 condition.
Sensation
Edema
Pain level
Ecchymosis
The Correct Answer is {"A":{"answers":"B,C"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B,C"}}
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A.Taping the tube to the child's cheek is not a recommended practice. It can cause skin irritation, discomfort, or even accidental removal of the tube. Proper securing of the tube to the abdomen using appropriate devices is the preferred method to prevent dislodgement.
B.Applying lubricant to the site is not necessary or recommended. The gastrostomy tube should be kept clean and dry. If any secretions or debris are present, they should be gently cleaned with mild soap and water, followed by thorough rinsing and drying.
C.Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.
D.Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling of the gastrostomy tube. This can be done using appropriate securing devices, such as adhesive dressings or commercially available tube holders, as recommended by the healthcare provider.
Correct Answer is D
Explanation
Choice A rationale:
Instructing the client to abstain from sexual intercourse for one month is not necessary for the management of Chlamydia trachomatis. Instead, the client should be advised to abstain from sexual activity until they and their partner(s) have completed the prescribed course of antibiotics and are no longer contagious, which is usually within 7 days.
Choice B rationale:
Administering ceftriaxone via intermittent IV bolus is not the recommended route for treating Chlamydia trachomatis. The standard treatment for Chlamydia trachomatis infection is oral antibiotics, such as azithromycin or doxycycline. Intravenous administration is not typically required for uncomplicated cases.
Choice C rationale:
Scheduling the client for retesting in one week is not necessary if the client has received appropriate treatment and follows the prescribed course of antibiotics. Retesting is generally recommended 3 months after treatment, especially in cases of persistent or recurrent symptoms.
Choice D rationale:
Reporting the infection to the state department of health is a crucial action. Chlamydia trachomatis is a reportable sexually transmitted infection in many jurisdictions. Reporting helps public health authorities track the incidence of the disease, implement preventive measures, and allocate resources effectively to control its spread within the community. It is essential for the nurse to comply with legal and ethical obligations by reporting the infection to the appropriate health authorities.
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