Nokea
The nurse is continuing to care for the child
Diagnostic Results
1100:
X-ray of right arm: nondisplaced fracture of radius and ulna at the midpoint.
Assessment
1000:
Child is alert and appears developmentally appropriate for their age and well nourished.
Respirations easy and unlabored. Abdomen nondistended. Right forearm and fingers are
edematous. Ecchymotic area noted on outer aspect of the forearm. Radial pulse +2. Fingers
slightly cool to touch. Child can move fingers and reports a mild "tingling" sensation. Child
verbalizes a pain level of 4 on a scale of 0 to 10. Abrasion noted on right knee. No active
bleeding. Multiple areas of bruising noted on lower extremities in various stages of healing
1145:
Edema in right forearm and fingers is mildly increased. Child states that mild tingling in fingers
is unchanged. Able to move all fingers equally. Radial pulse is equal in both extremities, Right
hand fingers are slightly cooler than left hand fingers.
Select the 3 priority actions that the nurse should take.
- A. Review cast care instructions with the child's parents
- B. Administer Ibuprofen 200 mg PO
- C. Place a nonadherent dressing on the right knee abrasion.
- D. Explain the cast application procedure to the child.
- E. Apply ice packs to the fingers and along the right forearm.
- F. Elevate the affected forearm with pillows.
Correct Answer: B,C,F
Rationale: Administering pain relief, protecting the abrasion, and elevating the limb reduce swelling and promote comfort.
You may also like to solve these questions
A nurse is caring for a client who is receiving radiation therapy and is experiencing anorexia.
Which of the following actions should the nurse take?
- A. Provide the client with cold foods rather than hot foods
- B. Encourage the client to drink fluids with meals
- C. Offer the client large meals three times a day
- D. Advise the client to avoid high-protein foods
Correct Answer: A
Rationale: The correct answer is A because providing the client with cold foods rather than hot foods can help reduce nausea and vomiting, which are common symptoms of pregnancy. Cold foods are generally better tolerated by pregnant women experiencing morning sickness. Encouraging the client to drink fluids with meals (choice B) is important, but it is not the most immediate action to alleviate nausea. Offering the client large meals three times a day (choice C) may worsen nausea, as smaller, more frequent meals are typically recommended. Advising the client to avoid high-protein foods (choice D) is not necessary unless there are specific contraindications, as protein is important for fetal development.
A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication.
Which of the following interventions should the nurse include in the plan?
- A. Speak in a neutral tone when addressing the client.
- B. Force the client to take the prescribed medication.
- C. Encourage the client to discuss their delusions.
- D. Use humor to lighten the mood and build trust.
Correct Answer: A
Rationale: The correct answer is A: Speak in a neutral tone when addressing the client. This intervention is important as it helps maintain a calm and non-threatening environment, promoting effective communication with the client. Speaking in a neutral tone also conveys respect and understanding, which can help build trust and rapport.
Choice B is incorrect because forcing the client to take medication can lead to resistance and worsen the therapeutic relationship. Choice C may not be appropriate as encouraging a client to discuss delusions without proper training or expertise in addressing such issues could potentially exacerbate the situation. Choice D, using humor, may not be suitable in this context as it may not be well received by a client experiencing delusions.
A nurse is caring for a newborn.
Nurses' Notes
0640:
Weight 4200 gm (9 lb 4 oz), head circumference 35.5 cm (14 in)
Respiratory rate 68/min, with mild grunting.
0650:
Respiratory rate 72/min, with mild grunting
0700:
Respiratory rate 76/min, with moderate grunting and mild intercostal retractions.
The client is at risk for developing------- and----
- A. bronchopulmonary dysplasia
- B. transient tachypnea of the newborn
- C. tachycardia
- D. hypopycemia
Correct Answer: B,D
Rationale: Transient tachypnea and hypopycemia are common risks in newborns with respiratory distress.
The nurse is continuing to care for the child.
Assessment
1000:
Child is alert and appears developmentally appropriate for their age and well nourished.
Respirations easy and unlabored. Abdomen nondistended. Right forearm and fingers are
edematous. Ecchymotic area noted on outer aspect of the forearm. Radial pulse +2. Fingers
slightly cool to touch. Child can move fingers and reports a mild "tingling" sensation. Child
verbalizes a pain level of 4 on a scale of 0 to 10. Abrasion noted on right knee. No active
bleeding. Multiple areas of bruising noted on lower extremities in various stages of healing.
Complete the sentence using the lists of options.The child is at highest risk for developing------------evidenced by the child's-----------
- A. compartment syndrome
- B. circulatory impairment
- C. abrasion and bruising
- D. paresthesia
- E. nerve damage
Correct Answer: B,D
Rationale: Circulatory impairment is evidenced by paresthesia (tingling), indicating compromised blood flow.
A nurse is caring for an infant who has coarctation of the aorta.
Which finding should the nurse identify as expected?
- A. Weak femoral pulses
- B. Bounding pulses in the lower extremities
- C. Cyanosis of the hands and feet
- D. Frequent episodes of bradycardia
Correct Answer: A
Rationale: The correct answer is A: Weak femoral pulses. In pediatric patients, weak femoral pulses are expected due to the normal physiological differences in vascular resistance between upper and lower extremities. This is known as the "femoral pulse lag." Bounding pulses in the lower extremities (choice B) would be abnormal and could indicate a vascular disorder. Cyanosis of the hands and feet (choice C) suggests poor perfusion and oxygenation, which is concerning. Frequent episodes of bradycardia (choice D) could indicate cardiac issues and are not expected in a healthy pediatric patient.