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 C
Explanation
Rationale:
A. "Placement of the catheter is confirmed by a CT scan.": Catheter placement is not routinely confirmed by CT scan. Instead, correct placement of a central venous catheter is verified by a chest X-ray immediately after insertion to ensure proper tip location.
B. "You will be under general anesthesia for this procedure.": General anesthesia is not required for placement of a nontunneled percutaneous central venous catheter. The procedure is typically performed using local anesthesia and aseptic technique at the bedside.
C. "The provider will wear a mask while performing the procedure.": The provider wears a mask, sterile gown, gloves, and cap as part of strict sterile technique during insertion to prevent catheter-related bloodstream infections.
D. "Your head will be elevated as high as possible while the catheter is inserted.": The client’s head is not elevated during insertion. Instead, a flat or slight Trendelenburg position is used to distend neck veins and reduce the risk of air embolism.
Correct Answer is ["A","B","F","H","I"]
Explanation
Rationale for Correct Findings:
• Temperature 38.2° C (100.8° F): Fever in a postpartum client may indicate infection such as endometritis, mastitis, or wound infection. Early detection is essential to prevent progression to sepsis, especially after cesarean birth and prolonged rupture of membranes.
• Heart rate 104/min: Tachycardia in the postpartum period may reflect infection, pain, or hypovolemia. Coupled with fever and leukocytosis, it indicates systemic inflammatory response requiring urgent evaluation.
• Client reports feeling unwell: Subjective complaints of malaise can be an early indicator of infection or postpartum complications. When combined with objective findings like fever and elevated WBC, it requires prompt follow-up.
• WBC count 33,000/mm³: Significantly elevated leukocytes indicate a severe inflammatory or infectious process. Immediate assessment and intervention are necessary to prevent progression to sepsis.
• Uterus firm at 1 cm above the umbilicus and tender to palpation; fundus boggy but firmed with massage: A boggy fundus and uterine tenderness can indicate uterine atony or early postpartum infection. These findings, especially with elevated temperature and WBC, require urgent monitoring and intervention.
• Moderate amount of dark brown, foul-smelling lochia: Foul-smelling lochia is abnormal and may signal endometritis, particularly after cesarean delivery and prolonged rupture of membranes. This requires prompt evaluation and potential initiation of antibiotics.
Rationale for Incorrect Findings:
• Breasts firm, heavy, and warm with moderate nipple discomfort while breastfeeding: These are expected findings related to milk engorgement. They are typical postpartum changes and can be managed with frequent breastfeeding or expressing milk.
• Surgical incision well approximated with slight edema, no redness or drainage: Slight edema at the incision site is normal post-cesarean. Absence of redness, warmth, or drainage indicates no infection requiring urgent intervention.
• BP 108/70 mm Hg: Blood pressure is within the acceptable range for a postpartum client and does not indicate immediate concern.
• Respiratory rate 18/min: This is within normal limits for an adult and does not require urgent intervention.
• SaO2 97% on room air: Oxygen saturation is within normal range and indicates adequate oxygenation, not requiring immediate follow-up.
• Hemoglobin 11.1 g/dL: This value is within normal postpartum limits, indicating no acute anemia or need for immediate intervention.
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