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?
Capillary refill less than 2 seconds.
Tingling in the right foot.
Respiratory rate 24/min.
2+ right pedal pulse.
The Correct Answer is B
Choice A rationale
Capillary refill less than 2 seconds is a normal finding and suggests adequate perfusion. It is not indicative of a priority concern in this context.
Choice B rationale
Tingling in the right foot can indicate nerve damage or compromised circulation, which is critical to address in a patient with a fracture. This symptom could suggest complications like compartment syndrome, requiring immediate medical attention.
Choice C rationale
Respiratory rate of 24/min is slightly elevated but not directly related to the fracture's immediate complications. It requires monitoring but is not the priority.
Choice D rationale
A 2+ right pedal pulse indicates a normal pulse and adequate circulation in the foot. While important, it does not represent an immediate concern in this context.
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Correct Answer is A
Explanation
Choice A rationale
Asking whether the imaginary person had a name can help determine if the child's imaginative play is typical for their age group. Preschool-aged children often engage in imaginative play, including conversations with imaginary friends, which is a normal part of cognitive and social development.
Choice B rationale
Temper tantrums are more related to behavioral issues rather than imaginative play. While relevant to the child's overall behavior, this question diverts attention from the specific concern about imaginary play.
Choice C rationale
This question could help identify if there are broader behavioral concerns, but it doesn't directly address the mother's specific worry about the imaginary friend. It is less targeted.
Choice D rationale
Understanding how well the child plays with others can provide insights into their social development, but it doesn't directly address the issue of imaginary play. It could be more pertinent as a follow-up question.
Correct Answer is D
Explanation
A. Elevated blood pressure is not an indication of dehydration; dehydration is more likely to cause a drop in blood pressure due to decreased blood volume.
B. Dehydration typically does not cause a low body temperature; instead, it can lead to an elevated temperature as the body conserves water.
C. Jugular vein distention is associated with fluid overload or heart failure, not dehydration.
D. Skin tenting, where the skin remains elevated after being pinched, is a classic sign of dehydration due to reduced skin elasticity.