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 B
Explanation
Choice A reason:
Mild pain in the hip region can be caused by various musculoskeletal issues, such as muscle strains, bursitis, or even referred pain from other areas. It is not a characteristic symptom of scoliosis.
Choice B reason
Scoliosis is characterized by an abnormal sideways curvature of the spine, which can cause uneven shoulders and pelvic heights. As the spine curves abnormally, it can lead to asymmetry in the shoulders and hips, which are noticeable during physical examination. This asymmetry is a key clinical sign that suggests the presence of scoliosis.
Choice C reason:
Limited range of motion (ROM) of the hips is more likely related to hip joint issues or musculoskeletal conditions affecting the hips, not specifically scoliosis.
Choice D reason:
Exaggerated curvature of the sacrum may indicate other spinal abnormalities or conditions affecting the lower back, but it is not typically associated with scoliosis, which primarily affects the curvature of the spine higher up in the thoracic or lumbar regions.
Correct Answer is A
Explanation
A is correct because hospice care includes bereavement support for the family for up to a year after the client's death.
B is incorrect because the hospice nurse does not administer pain medication, but rather teaches the family how to manage the client's pain at home.
C is incorrect because respite care is one of the services that hospice provides to allow the family to take a break from caregiving.
D is incorrect because hospice care does not aim to prolong life, but rather to provide comfort and quality of life for the client and the family.
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