A nurse is caring for an adolescent client who has a fractured right tibia and a cast. Which of the following findings should the nurse report to the provider?
Pain following range-of-motion exercises.
Pruritus under the cast.
Presence of swelling while the extremity is dependent.
Coolness of the toes.
The Correct Answer is A
Choice A rationale:
Pain following range-of-motion exercises is a significant finding that should be reported to the provider. It could indicate the possibility of complications, such as further injury or impaired healing. Adolescents with fractured bones are often encouraged to perform range-of-motion exercises to prevent stiffness and promote circulation. However, increased pain during or after these exercises could indicate problems like muscle strain or improper alignment of the fracture, which need to be addressed promptly.
Choice B rationale:
Pruritus (itching) under the cast is common and can be expected due to the accumulation of dead skin cells and sweat. While it can be uncomfortable for the client, it's not an urgent concern that requires immediate reporting to the provider. Strategies to alleviate itching, such as using a cool blow dryer under the cast, can be taught to the client.
Choice C rationale:
The presence of swelling while the extremity is dependent is a normal response to gravity and is not an alarming finding. Swelling when the extremity is dependent is expected, especially within the initial stages of fracture healing. It suggests that the blood supply is reaching the area for healing purposes. Elevation and rest can help reduce the swelling.
Choice D rationale:
Coolness of the toes could be due to reduced blood flow, but this finding alone may not be an immediate concern. It's essential to consider the client's overall circulation, capillary refill, and presence of pulses. If other signs of impaired circulation, such as pallor or delayed capillary refill, are present along with coolness, it might indicate compromised vascular supply. However, based on the information provided, this choice is not as urgent as reporting pain following range-of-motion exercises.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Swelling around the eyelids and mouth could indicate an allergic reaction, which can be severe in some cases. Anaphylaxis is a life-threatening reaction that can occur after immunizations. The nurse's priority is to assess and address any signs of an allergic reaction promptly. Swelling of the face, particularly around the eyes and mouth, is a red flag for potential anaphylaxis, and immediate intervention is necessary to prevent further complications.
Choice B rationale:
A temperature of 100.7 degrees Fahrenheit is considered a mild fever. While it's important to monitor for fever after immunizations, a mild fever alone may not be the nurse's top priority, especially if the child is otherwise stable. Fever can be a common post-immunization response and is often self-limiting.
Choice C rationale:
While monitoring the child's intake is important, only eating 2 ounces during the last feeding is not a priority concern compared to potential allergic reactions or fever. A temporary decrease in appetite following immunizations can be expected and might resolve on its own.
Choice D rationale:
Crying when the injection site is touched is a common response to discomfort from the shot. While it's essential to provide comfort and support to the child, this finding is not indicative of a severe reaction. It's not the nurse's priority compared to potential signs of an allergic reaction or a more significant fever.
Correct Answer is B
Explanation
Choice A rationale:
"Provide your child with long-term goals to increase self-esteem." While setting long-term goals can indeed contribute to increasing a child's self-esteem, this choice may not be the most directly related to promoting a child's learning, especially for a child with attention deficit hyperactivity disorder (ADHD). Children with ADHD often struggle with attention and focus, and setting long-term goals might not address their immediate needs in terms of learning strategies.
Choice B rationale:
"Offer your child frequent breaks in activity during the day." Children with ADHD often benefit from frequent breaks in activities to help manage their attention and energy levels. These breaks can help prevent mental fatigue, increase focus, and enhance overall learning. This choice is appropriate for promoting the child's learning and is often recommended as part of ADHD management strategies.
Choice C rationale:
"Administer your child's medication at bedtime to prevent insomnia." This statement is not necessarily accurate for all medications used to treat ADHD. Some ADHD medications can indeed cause insomnia as a side effect, but the timing of medication administration can vary based on the specific medication and the child's individual response. It's essential for parents to follow the healthcare provider's instructions regarding medication timing.
Choice D rationale:
"Schedule a different routine for your child each day." Children with ADHD often benefit from consistent routines and schedules, as they provide structure and predictability, which can help manage their symptoms. Introducing a different routine each day could actually exacerbate symptoms and make it more challenging for the child to focus and engage in learning activities.
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