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 D
Explanation
Rationale:
A. Apply a cool pack to the perineum: Cool packs are useful for reducing perineal swelling and discomfort after delivery, not during the latent phase of labor. At this stage, the client benefits more from relaxation and distraction techniques that help manage early contractions.
B. Encourage the client to use pant-blow breathing: Pant-blow or patterned breathing is recommended during the transition phase of labor, when contractions are intense and close together. In the latent phase, the client typically uses slow, relaxed breathing to conserve energy and remain calm.
C. Have their support person leave the room when the doula arrives: Both the doula and the support person play complementary roles in providing emotional and physical support. Asking the partner to leave can increase anxiety and reduce the sense of safety.
D. Lightly stroke the abdomen during contractions: Light abdominal stroking, known as effleurage, promotes relaxation and distraction from contraction pain during the latent phase. This technique aligns with natural childbirth methods by using soothing touch to reduce tension and enhance comfort without pharmacologic intervention.
Correct Answer is D
Explanation
Rationale:
A. "I understand that my scars will eventually fade.": This statement reflects acceptance and understanding of the healing process rather than distress about appearance. It indicates the client is cognitively processing changes without expressing body image disturbance.
B. "I am ready to join a breast cancer support group.": Willingness to participate in a support group demonstrates coping and adjustment. The client is seeking social and emotional support, which is a healthy response to surgery rather than a sign of altered body image.
C. "I want to have reconstructive surgery as soon as I can.": Desire for reconstructive surgery is a proactive coping strategy and a way to regain body image control. It reflects planning for recovery rather than expressing negative feelings about current body changes.
D. "I prefer to leave the lights off when I am changing my clothes.": Avoiding exposure of the body and seeking darkness when changing clothes indicates discomfort and distress with physical appearance. This behavior reflects an altered body image and difficulty accepting the changes after surgery.
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