A nurse is caring for a 9-year-old client 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 nondistended. 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 noted on lower extremities in various stages of healing.
Exhibit 3
Vital Signs
1000:
Temperature 36.80 C (98.20 F)
Heart rate 102/min
Respiratory rate 22/min
BP 100/60 mm Hg
Oxygen saturation 98% on room air
Right forearm and fingers are edematous.
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 noted on lower extremities in various stages of healing
Heart rate 102/min
Respiratory rate 22/min
The Correct Answer is ["A","C","D","E"]
Findings Requiring Immediate Follow-Up
Right forearm and fingers are edematous: Swelling after trauma can indicate a fracture, soft tissue injury, or early compartment syndrome. Edema can compromise circulation and should be assessed promptly.
Fingers slightly cool to touch: Cool fingers may indicate reduced perfusion to the extremity, which is concerning after trauma. Immediate assessment of capillary refill, color, and temperature is necessary.
Child verbalizes a pain level of 4/10: Pain in children, even moderate, requires attention because it can indicate significant underlying injury and may escalate. Pain assessment and management should be prioritized.
Child can move fingers and reports a mild "tingling" sensation: Tingling may indicate nerve involvement or early neurovascular compromise, even if movement is preserved. Timely evaluation is essential.
Findings Not Requiring Immediate Follow-Up
Radial pulse +2: A +2 radial pulse is normal and indicates adequate arterial flow, so it does not require immediate intervention.
Multiple areas of bruising noted on lower extremities in various stages of healing: In this scenario, the bruising is assumed to be from normal childhood activity or minor trauma. It does not automatically signify abuse and is not an urgent concern.
Heart rate 102/min: Slightly elevated heart rate may reflect pain or stress. It is within normal limits for a 9-year-old (70–120/min).
Respiratory rate 22/min: Within normal range for a 9-year-old (18–26/min) and not urgent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. “Client in room 302 has had high blood glucose levels.” This statement lacks specific data (values, trends, or interventions) and is too vague to be useful.
B. “Client in room 304 is here because they are seeking narcotics.” This is a judgmental and non-objective statement, violating professional communication standards.
C. "Client in room 303 takes too many medications for their condition." This is subjective and unprofessional; only factual data should be reported.
D. “Client in room 301 is in the cardiac catheterization laboratory.” Objective, relevant information about the client’s current location, procedures, and treatments should be included in a shift report to ensure continuity of care.
Correct Answer is A
Explanation
A. Sunken fontanels and dry mucous membranes indicate moderate to severe dehydration, a serious complication of gastroenteritis in infants. This requires prompt fluid replacement (oral or IV) to prevent hypovolemic shock.
B. A mild fever and slightly elevated pulse are expected findings in gastroenteritis and not immediately concerning.
C. Decreased appetite and irritability are common, mild symptoms of illness but not critical.
D. A small fluid deficit (30 mL over 24 hours) is minimal in an infant and does not indicate severe dehydration.
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