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 A
Explanation
Choice A rationale:
This action requires intervention by the nurse. Antiembolic stockings should be smooth and free of creases to ensure even pressure distribution along the legs. Creases, especially if on the front of the legs, can lead to areas of increased pressure, which might compromise circulation and increase the risk of skin breakdown or clot formation.
Choice B rationale:
Applying the stockings before the client gets out of bed is appropriate, as it ensures proper application and minimizes the risk of injury due to the client's leg swelling
Choice C rationale:
Asking the client to point their toes before applying the stockings is appropriate, as it helps with correct placement and reduces the risk of skin damage or discomfort
Choice D rationale:
Turning the stockings inside out (at least down to the heel) before applying them is a common technique to make it easier to position the stocking on the foot and leg properly. This method helps avoid excessive stretching of the stocking and ensures a better fit.
Correct Answer is A
Explanation
Choice A rationale:
The described cardiac rhythm with a wavy baseline, no distinguishable P waves, and an increased heart rate is consistent with atrial fibrillation. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to an irregular and often rapid heart rate. This rhythm is characterized by the absence of distinct P waves on the ECG.
Choice B rationale:
Ventricular asystole is a flatline on the ECG, indicating the absence of electrical activity in the heart. It is a life-threatening arrhythmia and requires immediate intervention with cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) protocols.
Choice C rationale:
Second-degree heart block is characterized by intermittent failure of atrial electrical impulses to conduct to the ventricles. This results in occasional dropped beats and a varying heart rate. It is not consistent with the described ECG findings in the question.
Choice D rationale:
Sinus tachycardia is a regular, fast heart rate originating from the sinoatrial (SA) node. In sinus tachycardia, P waves are present, indicating that the electrical impulses originate in the SA node. The described ECG findings do not match the characteristics of sinus tachycardia.
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