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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
Choice A rationale
Walks with one hand held typically occurs around 12 months as infants gain balance and coordination for upright movement.
Choice B rationale
Sits unsupported usually happens around 6 months when infants' core muscles are strong enough to hold their torso upright.
Choice C rationale
Turning pages in a book is a fine motor skill that develops around 12 months as hand-eye coordination improves.
Choice D rationale
Rolling from front to back typically occurs around 6 months as infants develop stronger neck and upper body muscles.
Correct Answer is B
Explanation
Choice A rationale
Learning to use creative energies is associated with the initiative vs. guilt stage, typically seen in preschool-aged children. During this stage, children assert control and power over their environment through directing play and other social interactions.
Choice B rationale
Defining a sense of self pertains to the identity vs. role confusion stage, which occurs in adolescence. This stage focuses on developing a personal identity and a sense of self. Adolescents explore different roles, beliefs, and values to form a unique identity.
Choice C rationale
Building a sense of trust is linked with the trust vs. mistrust stage, experienced in infancy. In this stage, infants learn to trust their caregivers and environment if their needs are consistently met, establishing a foundation for future relationships.
Choice D rationale
Learning to perform tasks independently corresponds to the autonomy vs. shame and doubt stage, typical of toddlers. In this stage, children develop a sense of personal control over physical skills and a sense of independence.