A nurse is caring for a group of clients on a pediatric unit. Which of the following clients is most at risk for insufficient vascular perfusion?
A toddler who is receiving intravenous fluids
A school-age child who is in a spica cast
An adolescent who has a urinary tract infection
A preschooler who has otitis media
The Correct Answer is B
A. Receiving IV fluids is important but it doesn't typically put a child at risk for insufficient vascular perfusion unless there are complications like fluid overload or infiltration.
B. A spica cast can restrict movement and potentially impair circulation to the affected limb, increasing the risk of insufficient vascular perfusion.
C. A urinary tract infection primarily affects the urinary system and doesn't directly impact vascular perfusion.
D. Otitis media is an ear infection and does not typically affect vascular perfusion.
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Related Questions
Correct Answer is A
Explanation
A. The FLACC (Faces, Legs, Activity, Cry, Consolability) pain scale is ideal for assessing pain in toddlers, especially those who are cognitively impaired. It relies on observable behaviors rather than self-report.
B. A visual analog scale requires the patient to rate pain on a linear scale, which is not suitable for a toddler, especially one who is cognitively impaired.
C. While the FACES pain scale is useful for older children who can understand facial expressions, it is not appropriate for toddlers, especially those with cognitive impairments.
D. The CRIES pain scale is primarily used for neonates, not toddlers.
Correct Answer is A
Explanation
A. The Tumbling E chart is a suitable tool for assessing visual acuity in young children who may not yet know their letters. It uses the letter "E" in various orientations (up, down, left, right), and the child is asked to identify the direction the "E" is facing. This method is appropriate for children who are at least 3 years old and can follow simple directions.
B. In a visual acuity assessment, it is typically standard to test each eye separately after assessing both eyes together. Testing both eyes together initially can help gauge how the child performs with their full visual capability, but it’s essential to test each eye individually to accurately determine if there is a difference in visual acuity between the two eyes.
C. For a visual acuity test using a standard Snellen chart, positioning the child 4.6 meters (15 feet) away from the chart is correct. However, younger children, especially those who might not be able to focus or remain still at that distance, may sometimes be tested from a shorter distance. For preschool-aged
children, the testing distance can be adapted to accommodate their ability to focus and understand the task.
D. Testing visual acuity without glasses first is not the recommended approach if the child already wears corrective lenses. If the child uses glasses or other corrective lenses, you should assess their visual acuity with the glasses on, as this provides the most accurate representation of their vision with their current correction.
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