A nurse is caring for a toddler who has a short leg cast. Which of the following findings should the nurse report to the provider?
Warm temperature of the distal extremity
Positive pedal pulse in the distal extremity
Pallor of the distal extremity
Mobility of the distal extremity
The Correct Answer is C
A. Warm temperature of the distal extremity: Warmth is a normal finding and indicates proper blood flow to the extremity.
B. Positive pedal pulse in the distal extremity: A positive pedal pulse is a good sign indicating that circulation is adequate in the extremity.
C. Pallor of the distal extremity: Pallor can indicate compromised blood flow or ischemia, which is a serious condition that needs immediate attention. This could be a sign that the cast is too tight or that there is another issue affecting circulation.
D. Mobility of the distal extremity: Mobility of the distal extremity indicates that the cast is not too tight and that nerve function is likely intact. It is a positive sign and generally not a concern unless there are other symptoms.
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Related Questions
Correct Answer is D
Explanation
A. Administering an antidepressant: While medication may be part of the treatment plan, initial assessment to determine severity and safety is crucial.
B. Encouraging group therapy: Group therapy can be helpful, but assessing suicide risk comes first.
C. Assisting with ADLs (Activities of Daily Living): Helping with daily tasks might be needed, but assessing suicide risk is more urgent.
D. Ask the client if he is considering harming himself. Suicidal ideation is a serious symptom of depression and requires immediate assessment. Safety is the top priority.
Correct Answer is A
Explanation
A. Provide for periods of rest. Correct. Children with heart failure have reduced exercise tolerance and fatigue easily. Regular periods of rest help prevent overexertion and cardiac strain.
B. Increase the child's oxygen flow rate until the child no longer has cyanosis. This can be dangerous. Oxygen therapy should be used as prescribed by a healthcare provider, as excessive oxygen can lead to oxygen toxicity or other complications, especially in children with heart conditions.
C. Withhold digoxin if the child's pulse is greater than 100/min. Digoxin is typically withheld if the heart rate is too low (bradycardia), not high. The nurse should follow specific parameters set by the healthcare provider, but a pulse greater than 100/min is not a standard reason to withhold digoxin.
D. Weigh the child once each month. In children with heart failure, daily weights are important to monitor fluid status and detect worsening heart failure. Monthly weighing is not frequent enough.
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