A nurse is caring for a toddler who had a cast applied 2 hr ago due to multiple fractures of the right hand. Which of the following findings should the nurse report immediately to the charge nurse?
The parent reports the child will not keep the arm elevated on the pillow.
The fingers on the right hand have a capillary refill of 4 seconds.
The fingertips of the right hand are swollen and bruised.
The child is not attempting to move her right arm or fingers.
The Correct Answer is B
A. The parent reports the child will not keep the arm elevated on the pillow: Not a priority. While elevation is important, it is not immediately concerning.
B. The fingers on the right hand have a capillary refill of 4 seconds: Correct. A capillary refill time of more than 2 seconds indicates poor perfusion, which can be a sign of compartment syndrome, a serious complication.
C. The fingertips of the right hand are swollen and bruised: Concerning, but swelling and bruising can be normal post-injury. Immediate concern is perfusion.
D. The child is not attempting to move her right arm or fingers: Concerning, but can be due to pain or fear. Poor perfusion (B) is a more immediate threat.
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Related Questions
Correct Answer is D
Explanation
A. "Lice can jump from one child to another." Lice do not jump or fly; they crawl from one person to another through direct contact or by sharing personal items like hats, combs, or bedding. This statement is incorrect.
B. "Washing your child's hair daily will prevent lice." Regular hair washing does not prevent lice infestations. Lice infest clean and dirty hair alike, and prevention involves avoiding direct head-to-head contact and sharing personal items.
C. "Lice do not survive away from the host." While lice need a human host to survive, they can live for up to 1-2 days away from the host on objects like bedding, hats, or brushes. This statement is not completely accurate.
D. "Encourage your child to avoid sharing hats with other children." This is correct advice to prevent the spread of lice. Sharing hats or other personal items can facilitate the transmission of lice from one child to another.
Correct Answer is A
Explanation
A. Maintain night splints to the affected joint: Night splints help maintain joint position and function during sleep, preventing contractures and deformities. This is a common intervention in managing juvenile rheumatoid arthritis to ensure proper joint alignment and minimize pain and stiffness.
B. Encourage the child to take daytime naps: Daytime naps can lead to prolonged periods of immobility, which may increase stiffness and pain in joints. Maintaining regular activity and exercise is usually recommended to preserve joint function.
C. Administer opioids on a schedule: Opioids are not typically first-line treatment for juvenile rheumatoid arthritis due to potential side effects and risk of dependence. Nonsteroidal anti-inflammatory drugs (NSAIDs) and disease-modifying antirheumatic drugs (DMARDs) are more commonly used.
D. Apply cool compresses for 20 min every hour: Cool compresses may provide temporary relief for acute joint pain but are not recommended on a regular schedule due to risk of skin damage and reduced joint flexibility. Heat application is more commonly used for chronic pain relief in arthritis.
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