A nurse is caring for a 9-year-old client at a clinic.
The nurse reviews the assessment findings.
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 nondistended. 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 noted on lower extremities in various stages of healing.
Exhibit 3
Vital Signs
1000:
Temperature 36.80 C (98.20 F)
Heart rate 102/min
Respiratory rate 22/min
BP 100/60 mm Hg
Oxygen saturation 98% on room air
Right forearm and fingers are edematous.
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 noted on lower extremities in various stages of healing
Heart rate 102/min
Respiratory rate 22/min
The Correct Answer is ["A","C","D","E"]
Findings Requiring Immediate Follow-Up
Right forearm and fingers are edematous: Swelling after trauma can indicate a fracture, soft tissue injury, or early compartment syndrome. Edema can compromise circulation and should be assessed promptly.
Fingers slightly cool to touch: Cool fingers may indicate reduced perfusion to the extremity, which is concerning after trauma. Immediate assessment of capillary refill, color, and temperature is necessary.
Child verbalizes a pain level of 4/10: Pain in children, even moderate, requires attention because it can indicate significant underlying injury and may escalate. Pain assessment and management should be prioritized.
Child can move fingers and reports a mild "tingling" sensation: Tingling may indicate nerve involvement or early neurovascular compromise, even if movement is preserved. Timely evaluation is essential.
Findings Not Requiring Immediate Follow-Up
Radial pulse +2: A +2 radial pulse is normal and indicates adequate arterial flow, so it does not require immediate intervention.
Multiple areas of bruising noted on lower extremities in various stages of healing: In this scenario, the bruising is assumed to be from normal childhood activity or minor trauma. It does not automatically signify abuse and is not an urgent concern.
Heart rate 102/min: Slightly elevated heart rate may reflect pain or stress. It is within normal limits for a 9-year-old (70–120/min).
Respiratory rate 22/min: Within normal range for a 9-year-old (18–26/min) and not urgent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"A"}}
Explanation
Indicated:
Encourage high-calorie finger food: The client has experienced weight loss and decreased appetite, which can occur with depression. Offering high-calorie, easy-to-eat foods helps maintain adequate nutrition and prevents further weight loss.
Advise client to rise slowly from a sitting position: Trazodone can cause orthostatic hypotension due to its alpha-adrenergic blocking effects. Advising the client to rise slowly reduces the risk of dizziness or falls when standing.
Advise client to notify the provider if pregnant: Trazodone is contraindicated in pregnancy due to potential risks to the fetus. The client should inform the provider if pregnancy occurs or is suspected.
Encourage a regular sleep-wake schedule
Maintaining a consistent bedtime and wake time improves sleep hygiene, supports trazodone’s effectiveness for insomnia, and helps regulate mood and energy levels.
Not Indicated:
Instruct client to avoid foods that have been fermented or aged: This dietary restriction is necessary for clients taking monoamine oxidase inhibitors (MAOIs), not trazodone. Trazodone does not require tyramine restriction, so this intervention is unnecessary.
Encourage naps during the day when the client is tired: Daytime napping can disrupt nighttime sleep and worsen insomnia. The focus should be on promoting a consistent sleep routine rather than allowing extra daytime sleep.
Encourage client to sleep until later in the morning: Sleeping late can interfere with the circadian rhythm and reduce sleep quality. A consistent wake-up time is more beneficial for improving sleep patterns and mood.
Correct Answer is D
Explanation
Rationale:
A. Avoiding discussion of the newborn can invalidate the client’s grief and hinder emotional healing. The nurse should encourage expression of feelings and provide opportunities for memory-making.
B. Reassuring the client about future pregnancies minimizes the current loss and is not therapeutic during initial grief.
C. The client and family should decide who can see the newborn; encouraging contact can help with closure and mourning.
D. Offering photos and mementos (e.g., footprints, lock of hair, identification band) supports the grieving process and provides tangible memories that assist in acceptance and coping.
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