Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a 9-year-old child at a clinic.The nurse reviews the assessment findings.

Exhibits
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.

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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["B","C","E"]

Explanation

Rationale:
A. Bradypnea: Clients with end-stage kidney disease are more likely to experience Kussmaul respirations (rapid, deep breathing) as the body attempts to compensate for metabolic acidosis by exhaling excess carbon dioxide. Bradypnea is not a typical finding in renal failure and would indicate a different respiratory issue.

B. Oliguria: As kidney function declines, urine output decreases because the kidneys lose their ability to filter and excrete waste products effectively. Oliguria, or markedly reduced urine output, is a hallmark of end-stage renal disease and contributes to fluid overload.

C. Anemia: The kidneys normally produce erythropoietin, which stimulates red blood cell production. In end-stage kidney disease, decreased erythropoietin production leads to anemia, resulting in fatigue, pallor, and decreased oxygen-carrying capacity.

D. Hypotension: Clients with kidney failure often experience hypertension rather than hypotension due to fluid retention and activation of the renin-angiotensin-aldosterone system. Hypotension would be more characteristic of acute volume depletion, not chronic renal failure.

E. Edema: Impaired kidney function causes sodium and water retention, leading to fluid accumulation in tissues. Peripheral and periorbital edema are common manifestations of end-stage kidney disease due to reduced excretion of excess fluid.

A. Instruct the client's partner to assume care of the colostomy for the client. B. Encourage the client and partner to avoid expressing negative feelings about the colostomy. C. Transfer the client to a rehabilitation facility for instruction about self-management of the colostomy. D. Suggest the client join a support group for people who have colostomies.

Correct Answer is D

Explanation

Rationale:
A. Instruct the client’s partner to assume care of the colostomy for the client: Having the partner take over care may reinforce the client’s avoidance and hinder acceptance of the stoma. The goal is to promote gradual involvement and self-care.

B. Encourage the client and partner to avoid expressing negative feelings about the colostomy: Suppressing emotions can delay psychological adjustment. The nurse should instead encourage open discussion of feelings.

C. Transfer the client to a rehabilitation facility for instruction about self-management of the colostomy: Transferring the client is unnecessary at this stage and may add emotional stress. Education and emotional support can be effectively provided in the current care setting.

D. Suggest the client join a support group for people who have colostomies: Support groups provide opportunities to share experiences with others who have undergone similar surgeries. Peer support can reduce isolation, promote acceptance, and help the client adapt to lifestyle changes more confidently.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has end-stage kidney disease. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is caring for a client who has a newly created colostomy. The client's partner tells the nurse that the client refuses to look at the stoma. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is reviewing the medication administration record of a client who has benign prostatic hyperplasia (BPH). The client asks the nurse about taking saw palmetto. The nurse should instruct the client that which of the following medications interacts adversely with saw palmetto?

A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions should the nurse take to prepare the child for the procedure?

A nurse is teaching participants at a community center about advance directives. Which of the following information should the nurse include in the teaching?

A nurse is planning to administer 2 units of packed RBCs to an older adult client who has anemia. Which of the following actions should the nurse plan to take? (Select all that apply.)

A nurse is supervising an assistive personnel (AP) who is caring for a client with an indwelling urinary catheter. Which of the following actions taken by the AP indicates proper technique?

A charge nurse is teaching newly licensed nurses about postoperative procedures following abdominal surgery. Which of the following information should the charge nurse include?

A nurse on a postpartum unit is caring for a client. Exhibits Complete the following sentence by using the lists of options. The client is most likely experiencing dropdown as evidenced by the client’s dropdown

A nurse is teaching a client who is to undergo placement of a nontunneled percutaneous central venous access device. Which of the following statements should the nurse include in the teaching?