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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I'll give him acetaminophen for the pain.": Acetaminophen is used for pain relief and fever reduction but does not address disease transmission. It does not prevent the spread of the streptococcal infection.
B. "I'll discard his toothbrush and buy another.": This is crucial because the streptococcal bacteria can remain on the toothbrush, leading to potential reinfection or spreading the bacteria to others. Replacing the toothbrush after starting antibiotics helps to reduce the risk of reinfection.
C. "I'll continue to encourage him to drink lots of fluids.": Staying hydrated is important for recovery, but it does not prevent the transmission of the infection.
D. "I'll take his temperature every 4 hours.": Monitoring temperature helps track the child’s condition but does not prevent the spread of the infection.
Correct Answer is A
Explanation
A. Defining a sense of self: Adolescence is characterized by the search for identity and defining a sense of self. Erikson identifies this stage as "Identity vs. Role Confusion," where individuals explore and form their own identity separate from their family and childhood roles.
B. Learning to perform tasks independently: This is more typical of early childhood (Erikson's "Autonomy vs. Shame and Doubt"). During this stage, children are learning basic independence, such as dressing and feeding themselves.
C. Learning to use creative energies: This task is more relevant to the preschool age group (Erikson's "Initiative vs. Guilt"), where children engage in imaginative play and begin exploring their own ideas and creativity.
D. Building a sense of trust: Building a sense of trust is the primary task in infancy (Erikson's "Trust vs. Mistrust"), where infants develop trust in their caregivers and the world around them.
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