A nurse is caring for a toddler who had a cast applied 2 hours ago due to multiple fractures of the right hand.
Which of the following findings should the nurse report immediately to the charge nurse?
The child is not attempting to move her right arm or fingers.
The fingertips of the right hand are swollen and bruised.
The fingers on the right hand have a capillary refill of 4 seconds.
The parent reports the child will not keep the arm elevated on the pillow.
The Correct Answer is C
A nurse caring for a toddler who had a cast applied 2 hours ago due to multiple fractures of the right hand should report immediately to the charge nurse if the fingers on the right hand have a capillary refill of 4 seconds.
This could indicate that there is a problem with circulation.
Choice A is not an answer because it is not unusual for a child to not attempt to move her right arm or fingers after having a cast applied.
Choice B is not an answer because it is not unusual for the fingertips of the right hand to be swollen and bruised after having a cast applied.
Choice D is not an answer because it is not unusual for a child to not keep their arm elevated on a pillow after having a cast applied.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
E. The nurse should ensure the scale is balanced prior to use [A], place a disposable covering on the scale [B], weigh the infant in a diaper [D], and measure the infant from the crown of the head to the heels of the feet [E].
Choice C is incorrect because a stadiometer is used to measure standing height and is not appropriate for measuring the length of an infant who cannot stand.
Correct Answer is C
Explanation
ADHD primarily causes symptoms related to inattention, hyperactivity-impulsivity, or a combination of both.
With ADHD, someone may experience difficulties paying attention and staying organized.
Choice A is not correct because difficulty in acquiring reading skills is not a specific symptom of ADHD.
Choice B is not correct because difficulty using words in context is not a specific symptom of ADHD.
Choice D is not correct because difficulty performing self-grooming activities is not a specific symptom of ADHD.
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