A nurse is caring for a school-age child who has a fracture to the right femur. Which of the following findings is the nurse’s priority?
2+ right pedal pulse
Tingling in the right foot
Capillary refill less than 2 seconds
Respiratory rate 24/min
The Correct Answer is B
Choice A rationale
A 2+ right pedal pulse indicates a normal pulse and is not a cause for immediate concern in a child with a femur fracture.
Choice B rationale
Tingling in the right foot could indicate nerve damage or compromised blood flow, which can be a serious complication of a femur fracture. This should be the nurse’s priority as it could lead to long-term damage if not addressed promptly.
Choice C rationale
A capillary refill time of less than 2 seconds is considered normal and is not a cause for immediate concern in a child with a femur fracture.
Choice D rationale
A respiratory rate of 24/min is within the normal range for a school-age child and is not a cause for immediate concern in a child with a femur fracture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale
Spinal defects and sac-like protrusions are not typically associated with muscular dystrophy. They are more commonly seen in conditions like spina bifida.
Choice B rationale
Muscular weakness in the lower extremities is a common symptom of muscular dystrophy. This is due to the progressive degeneration of muscle fibers, which leads to weakness and loss of muscle mass.
Choice C rationale
Kyphosis of the lower spine can be a complication of muscular dystrophy. As the muscles supporting the spine weaken, the spine can curve abnormally, leading to kyphosis.
Choice D rationale
Purposeless, involuntary, abnormal movements are not typically associated with muscular dystrophy. These symptoms are more commonly seen in neurological conditions like Huntington’s disease or certain types of cerebral palsy.
Choice E rationale
An unsteady waddling gait is often seen in individuals with muscular dystrophy. This is due to the progressive weakness and loss of muscle mass in the lower extremities.
Correct Answer is D
Explanation
Choice D rationale
When a nurse notes the presence of bruises on a child’s arms and legs, the first action should be to obtain a detailed history. This can provide important context for the bruises and help determine whether they are likely the result of accidental injury or possible abuse.
Choice A rationale
Telling the child what will happen when the abuse is reported is not the first action a nurse should take. It is important to first gather all necessary information and report the suspected abuse to the appropriate authorities.
Choice B rationale
Requesting a social services referral is an important step when abuse is suspected, but it should come after obtaining a detailed history and reporting the suspected abuse.
Choice C rationale
Reporting the suspected abuse to the authorities is crucial when child abuse is suspected. However, it is important to first obtain a detailed history to provide as much information as possible to the authorities.
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