A nurse is caring for a 9-year-old child at a clinic.The nurse reviews the assessment findings.
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.
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.
The Correct Answer is ["C","E","F","H"]
Rationale for Correct Choices:
• Right forearm and fingers are edematous: Swelling after trauma can indicate a fracture, severe soft tissue injury, or early compartment syndrome. Prompt assessment and imaging are necessary to prevent complications such as impaired circulation or permanent tissue damage.
• Fingers slightly cool to touch: Cool fingers suggest compromised blood flow, possibly due to vascular injury or compartment syndrome. Immediate evaluation is critical to restore perfusion and prevent ischemic injury.
• Child can move fingers and reports a mild "tingling" sensation: Paresthesia signals potential nerve compression or early compartment syndrome. Timely intervention can prevent permanent nerve damage or loss of function.
• Multiple areas of bruising are noted on lower extremities in various stages of healing: Bruises in different stages of healing may indicate non-accidental trauma. This finding requires urgent reporting and investigation according to child protection policies.
Rationale for Findings Not Requiring Immediate Follow-Up
• Respirations easy and unlabored: Normal respiratory effort indicates that airway and oxygenation are adequate, so no immediate intervention is required.
• Abdomen non-distended: A soft, non-distended abdomen suggests no acute abdominal injury or internal bleeding, reducing the urgency of intervention.
• Ecchymotic area noted on outer aspect of the forearm: Localized bruising is consistent with the reported fall and mild trauma; it does not indicate immediate threat to circulation or nerve function.
• Child verbalizes a pain level of 4 on a scale of 0 to 10: Moderate pain is expected after minor trauma and can be managed with standard analgesics; it does not indicate an emergent complication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Transfer on the client's weaker side when moving a client from a bed to a chair: Clients should be moved toward their stronger side to facilitate participation and reduce strain on both the client and the nurse. Transferring toward the weaker side increases risk of injury and reduces stability.
B. Raise the head of the bed when transferring a client from a bed to a stretcher: Raising the head of the bed does not directly enhance safe body mechanics or ergonomic principles during a transfer. Proper lifting techniques and devices are more critical for preventing injury.
C. Use a lateral transfer device when moving a client from a bed to a stretcher: Using a lateral transfer device, such as a sliding board or transfer sheet, minimizes manual lifting, reduces musculoskeletal strain, and follows ergonomic principles. It is a key safety strategy for both the client and healthcare staff.
D. Use a pillow underneath the client's head when repositioning a client in bed: Placing a pillow under the head supports comfort and alignment but does not relate to ergonomic principles or safe lifting techniques. Ergonomics focuses on body mechanics, positioning, and injury prevention for caregivers.
Correct Answer is C
Explanation
Rationale:
A. Ensure each individual can respond defensively about the conflict: Encouraging defensive responses escalates tension and does not promote resolution. The goal is to facilitate understanding and collaboration, not defensiveness.
B. Use passive listening techniques during conflict resolution: Passive listening may miss key information and prevent the manager from fully understanding the concerns. Active and empathetic listening is necessary to address the conflict effectively.
C. Gather individual information regarding the conflict: Collecting perspectives from each person involved helps the nurse manager understand the root causes, identify common themes, and develop an appropriate strategy for resolution. This is a critical step in structured conflict management.
D. Ask closed-ended questions about the conflict: Closed-ended questions limit responses and do not allow individuals to fully express their concerns or feelings. Open-ended questions are more effective for exploring issues in depth.
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