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. Assign the AP to ask the client if she has taken her antidiabetic medication today: Incorrect. Assessing medication use is a nursing responsibility and cannot be delegated to an AP.
B. Determine if the AP has the skills to perform the test: The nurse must ensure that the AP is competent to perform the task safely and accurately before delegation, as part of the nurse's responsibility in delegation.
C. Help the AP perform the blood glucose test: Incorrect. The task should be performed independently by the AP if delegated.
D. Have the AP check the medical record for prior blood glucose test results: Incorrect. Reviewing the medical record is a nursing responsibility and not typically delegated to an AP.
Correct Answer is C
Explanation
A. Storing oxygen tanks under the bed is not safe due to limited ventilation and fire hazards.
B. The oxygen gauge should be checked daily, not weekly, to monitor levels.
C. The oxygen tank should be placed away from curtains or drapes to reduce the risk of fire.
D. The oxygen tank wrench should be readily accessible in case of emergencies.
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