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A nurse is caring for an adolescent.
Admission Assessment
1400:

  • Adolescent brought to emergency department by parents following a fall while skateboarding.
  • Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.
  • Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm.
  • Abdomen soft and nontender with active bowel sounds in all four quadrants.
  • Right lower extremity with open wound and displaced bone.
  • Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.

Select the 4 findings that require follow-up.

A.

Blood pressure

B.

Capillary refill

C.

Pedal pulse

D.

Heart rate

E.

Skin temperature

F.

Pain

Answer and Explanation

Correct Answer : B,C,E,F

A. Blood pressure: A normal blood pressure for an adolescent is 110/70 mm Hg. The question does not provide the adolescent's blood pressure, so it cannot be determined if it requires follow-up or not.
B. Capillary refill: A normal capillary refill time is less than 2 seconds. A prolonged capillary refill time indicates impaired blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
C. Pedal pulse: A normal pedal pulse is +2 or +3. A weak pedal pulse (+1) indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.

D. Heart rate: A normal heart rate for an adolescent is 60 to 100 beats per minute. The question does not provide the adolescent's heart rate, so it cannot be determined if it requires follow-up or not.
E. Skin temperature: A normal skin temperature is warm and dry. A cool skin temperature indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
F. Pain: A pain level of 10 on a scale of 0 to 10 indicates severe pain that needs to be managed with appropriate analgesics and nonpharmacological interventions.
 


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Related Questions

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Explanation

Completed Sentence: The client is at risk for developing hemorrhagic stroke due to autonomic dysreflexia. Rationale: Hemorrhagic Stroke: This is a serious condition that can occur as a complication of a high spinal cord injury. Due to the injury at T4, the client may be at risk for blood pressure dysregulation, which can lead to a hemorrhagic stroke. Autonomic Dysreflexia: This condition is characterized by a sudden increase in blood pressure, often triggered by stimuli such as a full bladder, bowel distention, or pain. In this client, the headache rated 9/10, diaphoresis, flushed skin, agitation, labored breathing, and elevated blood pressure (185/105 mm Hg) are indicative of autonomic dysreflexia.

Correct Answer is B

Explanation

A. Chest x-ray is not correct because it is not related to valproic acid therapy or its adverse effects.

B. Serum liver enzyme levels is correct because valproic acid can cause hepatotoxicity and liver function tests should be monitored regularly.

C. ABGS is not correct because it is not indicated for valproic acid therapy or its adverse effects.

D. Urine culture and sensitivity is not correct because it is not related to valproic acid therapy or its adverse effects.

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