A nurse is caring for a 9-year-old child at a clinic.The nurse reviews the assessment findings.
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.
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.
The Correct Answer is ["C","E","F","H"]
Rationale for Correct Choices:
• Right forearm and fingers are edematous: Swelling after trauma can indicate a fracture, severe soft tissue injury, or early compartment syndrome. Prompt assessment and imaging are necessary to prevent complications such as impaired circulation or permanent tissue damage.
• Fingers slightly cool to touch: Cool fingers suggest compromised blood flow, possibly due to vascular injury or compartment syndrome. Immediate evaluation is critical to restore perfusion and prevent ischemic injury.
• Child can move fingers and reports a mild "tingling" sensation: Paresthesia signals potential nerve compression or early compartment syndrome. Timely intervention can prevent permanent nerve damage or loss of function.
• Multiple areas of bruising are noted on lower extremities in various stages of healing: Bruises in different stages of healing may indicate non-accidental trauma. This finding requires urgent reporting and investigation according to child protection policies.
Rationale for Findings Not Requiring Immediate Follow-Up
• Respirations easy and unlabored: Normal respiratory effort indicates that airway and oxygenation are adequate, so no immediate intervention is required.
• Abdomen non-distended: A soft, non-distended abdomen suggests no acute abdominal injury or internal bleeding, reducing the urgency of intervention.
• Ecchymotic area noted on outer aspect of the forearm: Localized bruising is consistent with the reported fall and mild trauma; it does not indicate immediate threat to circulation or nerve function.
• Child verbalizes a pain level of 4 on a scale of 0 to 10: Moderate pain is expected after minor trauma and can be managed with standard analgesics; it does not indicate an emergent complication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
Rationale:
• "We should notify the provider if the cast becomes loose over time.": A loose cast can fail to immobilize the fracture properly, risking displacement or delayed healing. Recognizing this and contacting the provider demonstrates proper understanding of cast care.
• "We should expect the swelling and tingling to worsen before it gets better.": While mild swelling and tingling may occur, increasing or worsening neurovascular symptoms can indicate complications such as compartment syndrome. The parent needs reinforcement that any worsening sensation or cold fingers should prompt immediate provider notification rather than being expected.
• "We need to be very careful about how we handle the cast for the first 2 days while it dries.": Handling a wet cast improperly can deform it and compromise fracture stabilization. Awareness of this indicates correct knowledge of initial cast care.
• "It is important that our child avoids placing anything inside the cast.": Inserting objects into the cast can cause skin irritation, pressure ulcers, or infection. Avoiding this demonstrates understanding of safe cast management.
• "We should prop the casted arm on pillows for the next 24 hours.": Elevation of the casted limb reduces swelling and promotes comfort. This reflects correct knowledge of post-cast care.
Correct Answer is ["A","D","E"]
Explanation
Rationale:
A. Limit visitors to 30 min per day: Limiting the duration of visitors helps minimize radiation exposure to others. Only short, necessary visits are allowed, and visitors are advised to maintain a safe distance to reduce the cumulative radiation dose received during contact with the client.
B. Place the client in a semi-private room: Clients with sealed internal radiation implants should always be placed in a private room to protect others from unnecessary radiation exposure. A semi-private room would increase the risk of exposing other patients to radiation.
C. Instruct visitors who are pregnant to remain 3 feet from the client: Pregnant visitors should be instructed not to enter the client’s room at all because of the high sensitivity of the fetus to radiation exposure.
D. Wear a lead apron when providing care: The nurse must wear a lead apron while providing direct care to shield against radiation exposure. The nurse should also stand at the client’s side rather than directly in front of or behind the radiation source to minimize exposure intensity.
E. Close the door to the client’s room: Keeping the client’s door closed helps contain the radiation within the room, preventing unnecessary exposure to staff and other clients in nearby areas. It is part of the standard protective measures for clients undergoing internal radiation therapy.
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