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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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Battery involves actual physical contact without consent.

B. Negligence refers to failing to provide appropriate care, leading to harm.

C. Assault occurs when a person is threatened with harm or offensive contact, creating fear, even if no physical contact occurs. Telling the client that a catheter will be inserted without consent can be perceived as a threat.

D. Libel is a false written statement that damages someone’s reputation.

A. Replace the indwelling urinary catheter. B. Perform the Credés maneuver. C. Maintain the irrigation solution rate. D. Warm the irrigation solution.

Correct Answer is C

Explanation

A. There is no need to replace the catheter unless it is obstructed or malfunctioning.

B. Credé’s maneuver is used for bladder emptying, not for continuous bladder irrigation.

C. Pink-tinged urine is expected in the first 24 hours after a transurethral resection of the prostate (TURP). The nurse should maintain the irrigation rate to prevent clot formation.

D. Warming the irrigation solution is not indicated.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not.. I found the title to the car today, signed over to me.
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom. Client reports not wanting to eat anymore. Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is observing a newly licensed nurse provide care for a client who is postoperative. The newly licensed nurse tells the client that she will insert a urinary catheter if the client will not void. Which of the following torts should the charge nurse identify as having occurred?

Correct Answer is C

Explanation

A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hr ago. The nurse notes pink-tinged urine in the drainage bag. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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