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.

Choice A rationale:

Placing the client's hands in warm water is a method to stimulate urination and is appropriate for clients experiencing difficulty voiding.

Choice B rationale:

Performing a fundal massage is incorrect choice in this scenario.

Choice C rationale:

Administering a benzodiazepine is not appropriate for this situation. Benzodiazepines are a class of medications primarily used for anxiety, insomnia, and seizures. There is no indication for the use of benzodiazepines in this case, as the client's inability to urinate is likely related to a physiological issue postpartum, not anxiety or seizures.

Choice D rationale:

Placing an ice pack on the client's perineum is not the correct intervention for this situation. Ice packs on the perineum are typically used to reduce swelling and relieve pain after childbirth. However, the client's inability to urinate suggests a potential issue within the urinary system, and a fundal massage to promote uterine contractions would be more appropriate.

The correct answer is: b. “Tighten your muscles before relaxing them when using muscle relaxation techniques.”

Rationale for Choice B: Progressive Muscle Relaxation (PMR) is a well-established technique used in stress management and relaxation therapy. It involves systematically tensing and then relaxing specific muscle groups throughout the body. By tensing the muscles first, individuals can become more aware of the contrast between tension and relaxation, thereby enhancing the relaxation response. This heightened awareness helps individuals recognize and release muscular tension more effectively, leading to deeper relaxation and stress relief.

Rationale for Choice A: Choice A suggests talking to someone admired as the first step in using mindfulness techniques to relax. However, mindfulness practices typically involve cultivating awareness of the present moment without judgment. While seeking support from others may be beneficial for stress management, it is not a foundational aspect of mindfulness practice. Mindfulness often entails individual introspection and observation of one's thoughts, feelings, and bodily sensations.

Rationale for Choice C: Choice C recommends breathing in through the mouth and out through the nose during deep breathing exercises. While there are various breathing techniques utilized in stress management, the typical recommendation for deep breathing exercises is to inhale through the nose and exhale through the mouth. Nasal breathing helps regulate the flow of air, optimizes oxygen exchange, and activates the parasympathetic nervous system, promoting relaxation and stress reduction.

Rationale for Choice D: Choice D proposes imagining a stimulating situation when practicing guided imagery. However, guided imagery is a relaxation technique that involves creating vivid mental images of calming and tranquil scenes, such as a serene beach or peaceful forest. The purpose of guided imagery is to evoke positive emotions, reduce stress, and induce a state of deep relaxation. Imagining stimulating situations may have the opposite effect, potentially increasing arousal and tension rather than promoting relaxation.

In summary, while all choices may have some relevance to stress management, Choice B is the most appropriate as it aligns with the established technique of Progressive Muscle Relaxation. Choices A, C, and D deviate from widely recognized relaxation methods and are therefore considered incorrect in this context.