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 D
Explanation
A. The client’s decision and advance directives should be respected. Contacting the family to override or debate the decision violates autonomy and confidentiality.
B. The client is competent and able to make decisions, so there is no need to defer to the health care surrogate.
C. Encouraging further hemodialysis contradicts the client’s expressed wishes and advance directives, violating autonomy.
D. The nurse should honor the client’s choice and discuss discharge planning that supports comfort-focused or palliative care, ensuring the client’s preferences are respected.
Correct Answer is ["B","C","E","F"]
Explanation
A. Sputum cultures are indicated for suspected respiratory infections, not myocardial infarction. This is incorrect.
B. A 12-lead ECG is the first diagnostic test for chest pain to identify ST-segment elevation or ischemic changes indicating myocardial infarction.
C. Antiplatelet therapy (e.g., aspirin) prevents further platelet aggregation and thrombus formation, which improves coronary blood flow during acute coronary syndromes.
D. ABGs may provide information about oxygenation, but are not routinely required unless severe respiratory compromise or acidosis is suspected. Priority is oxygen and cardiac assessment.
E. Preparing for cardiac catheterization (coronary angiography) is appropriate since this client shows positive troponins and unrelieved chest pain, indicating myocardial infarction requiring reperfusion evaluation.
F. Oxygen administration at 2 L/min via nasal cannula helps improve oxygenation (SpO₂ 89%) and reduces myocardial ischemia. Maintaining SpO₂ ≥ 90% is essential to minimize cardiac workload.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.