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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.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:
A. "Massage the ointment into the skin.": The ointment should not be massaged into the skin because doing so alters the absorption rate and can cause unpredictable vasodilation and hypotension.

B. "Spread the ointment in a thin, even layer.": The nurse should instruct the client to apply the prescribed amount of nitroglycerin ointment in a thin, even layer to a hairless area of the upper body or chest. This ensures consistent absorption of the medication.

C. "Apply the ointment to the forearm.": The forearm is not a recommended site for application. The preferred areas are the chest, back, or upper arm where the skin is less likely to be disturbed and has better absorption.

D. "Apply the ointment to the skin every 4 hr.": Nitroglycerin ointment is usually applied every 6 to 12 hours depending on the prescription, with a nitrate-free interval to prevent tolerance. Every 4 hours is not standard practice.

A. Sunken fontanels and dry mucous membranes B. Temperature 38° C (100.4° F) and pulse rate 124/min C. Pale and a 24-hr fluid deficit of 30 mL D. Decreased appetite and irritability

Correct Answer is A

Explanation

Rationale:
A. Sunken fontanels and dry mucous membranes: These findings indicate moderate to severe dehydration, which can quickly become life-threatening in an infant. Prompt notification of the provider is essential to initiate fluid replacement and prevent complications such as hypovolemic shock.

B. Temperature 38° C (100.4° F) and pulse rate 124/min: A low-grade fever and mildly elevated pulse are common in gastroenteritis and typically do not require immediate reporting unless accompanied by other concerning symptoms like poor perfusion or lethargy.

C. Pale and a 24-hr fluid deficit of 30 mL: A fluid deficit of 30 mL over 24 hours is minimal in an infant and not immediately concerning. Monitoring should continue, but urgent reporting is not necessary for this level of deficit.

D. Decreased appetite and irritability: These are expected symptoms of gastroenteritis in infants and can be managed with routine supportive care and monitoring. They are not specific indicators of severe dehydration requiring immediate provider intervention.

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Explanation

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Correct Answer is A

Explanation

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