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
Collecting objects like rocks reflects the interest in categorizing and organizing, which aligns with the industry vs. inferiority stage for school-age children.
Choice B rationale
Wanting to do well in school also fits with the industry vs. inferiority stage, where children gain pride from achieving tasks and being competent.
Choice C rationale
Doing simple math problems in one's head indicates cognitive development but doesn't directly align with the psychosocial development focus.
Choice D rationale
Following rules set by parents is important, but it's more about conforming to authority rather than indicating psychosocial development specific to industry vs. inferiority.
Correct Answer is C
Explanation
Choice A rationale
Social interaction is essential for development and can enhance emotional and psychological well-being. Isolation can negatively affect the child.
Choice B rationale
Restricting physical activity is counterproductive. Physical activity should be encouraged within safe limits to promote strength and coordination.
Choice C rationale
Encouraging independence and self-care skills helps the child develop autonomy and confidence, essential for managing daily activities and improving quality of life.
Choice D rationale
Promoting a sedentary lifestyle is detrimental to health. Physical activity and engagement in activities enhance physical and mental well-being.