A nurse is caring for a toddler who had a cast applied 2 hr ago due to multiple fractures of the right hand. Which of the following findings should the nurse report immediately to the charge nurse?
The parent reports the child will not keep the arm elevated on the pillow.
The fingers on the right hand have a capillary refill of 4 seconds.
The fingertips of the right hand are swollen and bruised.
The child is not attempting to move her right arm or fingers.
The Correct Answer is B
A. The parent reports the child will not keep the arm elevated on the pillow: Not a priority. While elevation is important, it is not immediately concerning.
B. The fingers on the right hand have a capillary refill of 4 seconds: Correct. A capillary refill time of more than 2 seconds indicates poor perfusion, which can be a sign of compartment syndrome, a serious complication.
C. The fingertips of the right hand are swollen and bruised: Concerning, but swelling and bruising can be normal post-injury. Immediate concern is perfusion.
D. The child is not attempting to move her right arm or fingers: Concerning, but can be due to pain or fear. Poor perfusion (B) is a more immediate threat.
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Related Questions
Correct Answer is D
Explanation
A. A school-age child who cries when the nurse is giving him an injection: Crying during an injection is a normal reaction for a child and does not indicate abuse.
B. A toddler who has multiple bruises on the shins of both legs and his parents report that he is clumsy: Bruises on the shins are common in toddlers due to normal play and falls. Without other concerning signs, this does not strongly indicate abuse.
C. A preschooler who has a BMI indicating obesity: While childhood obesity can be a sign of neglect in some cases, it is not a specific or immediate indicator of abuse without other signs.
D. An adolescent who asks to stay in the hospital because he likes the room: This is concerning because it might indicate that the adolescent is not feeling safe or comfortable at home, which could be a sign of abuse or neglect.
Correct Answer is B
Explanation
A. Brisk pupillary reaction to light: A brisk pupillary reaction to light is a normal neurological finding and does not indicate increased ICP. Increased ICP might present with a sluggish or unequal pupil response.
B. Irritability: Irritability is a common early sign of increased ICP in infants. Changes in behaviour, such as increased irritability or lethargy, can indicate a neurological problem, including increased pressure within the skull.
C. Tachycardia: Tachycardia (increased heart rate) is not a typical indicator of increased ICP. Bradycardia (decreased heart rate) is more commonly associated with increased ICP due to the pressure on the brainstem affecting autonomic functions.
D. Increased sensory response to painful stimuli: Increased sensory response is not typically indicative of increased ICP. In fact, as ICP worsens, a decrease in sensory response or altered level of consciousness is more likely.
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