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
Asymmetric thigh folds are a common sign of developmental dysplasia of the hip (DDH) in infants. This physical examination finding indicates that the hips are not aligned properly, which can cause the folds in the thighs to appear uneven.
Choice B rationale
A shortened thigh, rather than a lengthened one, on the affected side is more typical of DDH. It is due to the femoral head not being properly seated in the hip socket, which can cause a discrepancy in leg length.
Choice C rationale
An inwardly turned foot is not a characteristic finding of DDH. This symptom is more commonly associated with conditions affecting the feet and lower legs, such as clubfoot.
Choice D rationale
The absence of plantar reflexes is not typically associated with DDH. This reflex involves a different part of the nervous system and is not linked to hip dysplasia.
Correct Answer is D
Explanation
Choice A rationale
Threatening a shot can cause fear and anxiety, potentially making the child more resistant to taking medication in the future.
Choice B rationale
Hiding medication in food can lead to mistrust if the child discovers it, and it's not a sustainable long-term solution.
Choice C rationale
Telling the child the medicine tastes like candy is misleading and can lead to distrust. It's important to be honest while finding practical solutions.
Choice D rationale
Offering an ice pop prior can numb the taste buds, making the medication more palatable without deceit, and can build positive associations with taking medication.