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 B
Explanation
Choice A rationale
Feet size variations are typically not a focus in adolescent development comparisons between genders.
Choice B rationale
Height differences are significant during puberty, with boys often experiencing growth spurts at different times compared to girls.
Choice C rationale
Eyesight differences are not a common developmental comparison between adolescent boys and girls.
Choice D rationale
Speech development differences exist but are not typically a focal point of peer comparison during adolescence.
Correct Answer is D
Explanation
Choice A rationale
Assisting with crutch walking is necessary but should occur only after ensuring the cast is properly set and stable to avoid injury.
Choice B rationale
Avoiding touch until the cast is dry is unnecessary and impractical. The nurse can handle the cast gently without causing damage.
Choice C rationale
Using a heat lamp can lead to skin burns or uneven drying, which might weaken the cast.
Choice D rationale
Applying moleskin to the edges protects the child’s skin from irritation and breakdown, promoting comfort and skin integrity.