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 {"dropdown-group-1":"D","dropdown-group-2":"D"}
Explanation
Rationale for Correct Choices
• A change in mood: Isotretinoin can cause psychiatric adverse effects, including depression and suicidal ideation. Adolescents are particularly at risk, so any mood changes must be reported immediately to the provider for timely intervention and possible medication adjustment.
• Engagement in sexual activity: Isotretinoin is highly teratogenic, and pregnancy must be strictly avoided during therapy. Adolescents must notify the provider immediately if they engage in sexual activity, so proper pregnancy prevention measures and monitoring can be implemented.
Rationale for Incorrect Choices
• Dry mouth: While common with isotretinoin therapy, dry mouth is generally mild and manageable with hydration; it does not require immediate notification to the provider.
• The development of dry eyes: This is a known side effect of isotretinoin, often treated with lubricating drops. It is uncomfortable but not an urgent adverse effect requiring immediate reporting.
• Nausea: Mild gastrointestinal upset may occur but is typically self-limiting and does not necessitate urgent notification unless severe or persistent.
• Worsening of acne: Acne flare-ups can occur at the beginning of isotretinoin therapy but are expected and not considered an emergency; ongoing follow-up is sufficient.
• Sunburn: Increased photosensitivity is a known side effect. While the adolescent should take precautions, sunburn does not require immediate notification unless severe.
• Decreased night vision: Rare and usually reversible; it should be monitored but is not an immediate emergency unless it significantly impairs function.
Correct Answer is D
Explanation
Rationale:
A. Obtain a 12-lead ECG for the client: An ECG is important to assess for myocardial ischemia or infarction, but it should be done after immediate measures are taken to reduce myocardial oxygen demand.
B. Administer sublingual nitroglycerin to the client: Nitroglycerin helps relieve chest pain by dilating coronary arteries, but it should be given only after the client is safely seated or resting to prevent hypotension or injury.
C. Measure the client's vital signs: Vital signs provide valuable baseline data, but addressing the client’s immediate safety and reducing cardiac workload takes priority.
D. Have the client stop walking and sit down: Stopping activity decreases oxygen demand on the heart and prevents worsening ischemia or collapse, making it the first and most critical action.
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