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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 D

Explanation

A. "I had to retire because my boss didn't like me.": Indicates projection, attributing personal feelings to someone else.

B. "There were lay-offs at my company, so I journaled about what I accomplished during my career.": Indicates positive coping, not compensation.

C. "I'm so glad I've retired because the work was making me sick and depressed.": Indicates rationalization, justifying the situation.

D. "Since I retired, I have entered many gardening competitions.": The client is compensating for the loss of work-related identity by engaging in competitive gardening, a constructive coping strategy.

A. "It is easier to breathe and I'm not as short of breath." B. Lung sounds still diminished with crackles C. oxygen saturation is 92% D. pleuritic chest pain as 3 on a scale of 0 to 10 E. Drinking 2 L per day F. No wheezes detected

Correct Answer is ["A","B","C","D","E"]

Explanation

Easier to breathe and less short of breath: The client reports improvement in breathing, stating it is easier to breathe and they are less short of breath. This suggests that the respiratory status is improving, which is a key indicator of progress.

Lung sounds still diminished with crackles, but no wheezes detected: While lung sounds are still diminished and crackles remain, the absence of wheezes indicates that the client’s condition is stabilizing. Wheezing would be concerning for bronchospasm or worsening respiratory distress, so the absence of this finding is a positive development.

Oxygen saturation 92%: The client’s oxygen saturation has improved from 88% on room air (Day 1) to 92% on 1 L/min of oxygen. Although still slightly below the target of 94%–98%, this improvement is a sign that oxygenation is improving with the current treatment.

Pleuritic chest pain reduced to 3/10: The client's report of pleuritic chest pain has decreased from 6/10 to 3/10. This reduction in pain indicates a positive response to treatment and the improvement of the underlying infection.

Increased oral intake (drinking 2 L/day): The client is drinking 2 L of fluids per day, which indicates adequate hydration and may help with recovery, particularly in the context of respiratory and infection management.

Normal urine output (200 mL of clear yellow urine): The client’s urine output appears adequate, and the urine is clear and yellow, which suggests proper hydration and normal renal function, supporting overall recovery.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the coping strategies of a client who has recently retired. Which of the following statements by the client indicates that the client is using compensation as a defense mechanism?

Correct Answer is D

Explanation

Correct Answer is ["A","B","C","D","E"]

Explanation

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