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.
Blood pressure
Capillary refill
Pedal pulse
Heart rate
Skin temperature
Pain
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Goal – oriented is the correct answer. Obsessive-compulsive personality disorder (OCPD) is a personality disorder characterized by a pattern of preoccupation with orderliness, perfectionism, and control. Individuals with OCPD tend to be highly organized, detail-oriented, and focused on achieving their goals. They often set strict standards for themselves and others and are driven by a strong need for perfection in all aspects of their lives.
Choice B reason
Provocative behaviour is not a characteristic commonly associated with obsessive-compulsive personality disorder (OCPD). In fact, individuals with OCPD tend to be more reserved, cautious, and serious in their interactions with others.
Choice C reason:
Lack of empathy While individuals with OCPD may struggle with interpersonal relationships due to their rigid standards and expectations, they typically do not lack empathy. They might find it challenging to understand and relate to emotions or perspectives that do not align with their own, but this is different from a complete lack of empathy, which is more commonly seen in certain other personality disorders.
Choice D reason.
Lability refers to emotional instability or rapid and extreme shifts in emotions. This is not a typical feature of obsessive-compulsive personality disorder (OCPD). Individuals with OCPD tend to be emotionally restrained and might have difficulty expressing emotions, rather than experiencing emotional lability.
Correct Answer is C
Explanation
Choice A reason:
Discourage physical activity during the day is incorrect. Encouraging physical activity is generally beneficial for individuals with dementia. Regular exercise can improve mood, reduce agitation, and enhance overall health. However, the level and type of physical activity should be tailored to the individual's abilities and preferences.
Choice B reason
Use clothing with buttons and zippers is incorrect. Clothing with buttons and zippers can be challenging for individuals with dementia due to fine motor skill impairments and difficulty with dressing. It is often recommended to use clothing with simple closures, such as Velcro or elastic bands, to make dressing easier and more manageable for the individual.
Choice C reason:
Individuals with dementia may experience difficulties with communication, memory, and problem-solving, which can affect their ability to recognize and express the need to use the restroom. As a result, they may be at risk of urinary or bowel incontinence. To address this concern and promote the client's comfort and dignity, establishing a toileting schedule is essential. A consistent routine for bathroom breaks can help prevent accidents and improve the client's overall well-being.
Choice D reason:
Engage the client in activities that increase sensory stimulation is incorrect. While sensory stimulation activities can be enjoyable and engaging for individuals with dementia, it is essential to select activities that are appropriate and not overwhelming. Some individuals with dementia may become overstimulated, which can lead to agitation or distress. Activities should be tailored to the individual's preferences and abilities.
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