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A nurse is caring for a 9-year-old child at a clinic.

Exhibits

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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Breast cancer is not a contraindication unless the client has other risk factors for bleeding.

B. Recent eye surgery is a contraindication for warfarin because it increases the risk of bleeding in a delicate surgical site.

C. Warfarin is often used after a myocardial infarction to prevent thromboembolic events.

D. Thrombophlebitis is an indication, not a contraindication, for anticoagulation therapy like warfarin.

A. "Keep your feet together to provide a tight base of support." B. "Keep objects away from your center of gravity while lifting." C. "Bend at the waist when lifting objects from the floor." D. "Tighten abdominal muscles to improve balance."

Correct Answer is D

Explanation

A. "Keep your feet together to provide a tight base of support": Incorrect. Keeping feet together reduces stability; a wide base of support is recommended.

B. "Keep objects away from your center of gravity while lifting": Incorrect. Objects should be kept close to the center of gravity to reduce strain.

C. "Bend at the waist when lifting objects from the floor": Incorrect. Bending at the knees, not the waist, is the correct technique to prevent back injury.

D. "Tighten abdominal muscles to improve balance": Tightening the abdominal muscles provides core stability and reduces the risk of injury when lifting.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical history of a client who asks about the use of warfarin. The nurse should identify which of the following findings as a contraindication for the administration of this medication?

Correct Answer is B

Explanation

An occupational health nurse is providing teaching to a group of factory workers about proper lifting techniques. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A home nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan monitor?

A nurse is caring for a client whose child died from cancer. The client states, "It's hard to go on without him." Which of the following questions should the nurse ask the client first?

A nurse is caring for a client who is in the active phase of labor and has decided to have a natural childbirth. Which of the following pain management techniques should the nurse suggest?

A nurse is caring for a client. Exhibits The nurse is caring for a client on the postpartum unit. The nurse is caring for the client following an emergency cesarean birth. Which of the following findings indicate an improvement in the client's condition? Select all that apply.

A nurse is caring for a client who has respiratory depression from an opioid administration. After administering naloxone to the client, which of the following findings should the nurse expect?

A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?

A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in the coronary artery. Which of the following actions should the nurse include in the plan of care?

A nurse is caring for a client who is 1 hr postpartum and unable to urinate. Which of the following actions should the nurse take?