A nurse is caring for a 9-year-old child at a clinic.
The nurse reviews the assessment findings.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
Assessment
Respirations easy and unlabored. Abdomen non-distended. Right forearm and fingers are edematous. Ecchymotic area noted on outer aspect of the forearm. Radial pulse +2. Fingers slightly cool to touch. Child can move fingers and reports a mild "tingling" sensation. Child verbalizes a pain level of 4 on a scale of 0 to 10. Multiple areas of bruising are noted on lower extremities in various stages of healing.
Vital Signs
Temperature 36.8° C (98.2° F)
Heart rate 102/min Respiratory rate 22/min
BP 100/60 mm Hg
Oxygen saturation 98% on room air
Respirations easy and unlabored
Right forearm and fingers are edematous
Ecchymotic area noted on outer aspect of the forearm
Radial pulse +2
Fingers slightly cool to touch
mild "tingling" sensation
Child verbalizes a pain level of 4 on a scale of 0 to 10
Multiple areas of bruising are noted on lower extremities in various stages of healing
Oxygen saturation 98% on room air
The Correct Answer is ["B","C","E","F","H"]
Assessment
Respirations easy and unlabored. Abdomen non-distended. Right forearm and fingers are edematous. Ecchymotic area noted on outer aspect of the forearm. Radial pulse +2. Fingers slightly cool to touch. Child can move fingers and reports a mild "tingling" sensation. Child verbalizes a pain level of 4 on a scale of 0 to 10. Multiple areas of bruising are noted on lower extremities in various stages of healing.
Vital Signs
Temperature 36.8° C (98.2° F)
Heart rate 102/min
Respiratory rate 22/min
BP 100/60 mm Hg
Oxygen saturation 98% on room air
Rationale:
Edema in the right forearm and fingers: The edema, particularly in the right forearm, may indicate a possible fracture or soft tissue injury. This requires immediate follow-up, including further assessment, potential imaging (e.g., X-ray), and intervention to rule out bone fractures, compartment syndrome, or significant tissue damage.
Fingers slightly cool to touch: This could indicate compromised circulation to the fingers, potentially due to swelling or a more serious injury like a fracture causing compression or vascular injury. Immediate follow-up is necessary to assess for any signs of impaired circulation, which could require urgent medical intervention.
Mild "tingling" sensation in the fingers: The tingling sensation might indicate nerve involvement or compression, which could be related to a fracture or soft tissue injury. Immediate follow-up is needed to assess for nerve damage or compartment syndrome, both of which require timely management to prevent long-term damage.
Multiple areas of bruising in various stages of healing: While this finding does not require immediate follow-up in the context of the current injury, it could raise concerns about possible underlying issues such as bleeding disorders or abuse. Although not an immediate concern, this warrants further investigation in the longer term.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Read medication labels at least two times prior to administration: Labels should be read three times (when retrieving, preparing, and administering).
B. Avoid preparing medications for more than two clients at one time: Reduces the risk of medication errors by minimizing task-switching and confusion.
C. Inform clients about the action of each medication prior to administration: While educating clients is essential, it is not always required before every medication.
D. Complete an incident report if a client vomits after taking a medication: An incident report is typically required only for errors or adverse events.
Correct Answer is ["B","D","E"]
Explanation
A. Blood pressure – The client's blood pressure of 114/56 mm Hg is within an acceptable range and does not indicate hypotension or hypertension.
B. Temperature – A temperature of 38.6°C (101.5°F) is indicative of fever, which is concerning in a client undergoing chemotherapy due to their increased risk of infection (febrile neutropenia). Prompt evaluation and intervention are necessary to prevent sepsis.
C. Potassium level – The client's potassium level of 3.6 mEq/L is within the normal range (3.5 to 5 mEq/L) and does not require immediate intervention.
D. WBC count – The client's WBC count has decreased to 3,800/mm³, which is below the normal range (5,000 to 10,000/mm³), indicating leukopenia. This places the client at a higher risk for infection, requiring close monitoring and potential interventions.
E. Breath sounds – The presence of crackles at the lung bases suggests possible pulmonary complications, such as fluid overload, infection (e.g., pneumonia), or early signs of acute respiratory distress syndrome (ARDS). This finding warrants further assessment and intervention.
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