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 D
Explanation
Choice A rationale
Hearing tests are important for children, but they are typically conducted earlier in childhood to detect any hearing impairments that may affect speech and language development.
Choice B rationale
Reading screenings are not typically part of routine health checks at this age and are more related to educational assessments.
Choice C rationale
Eye screenings are also important but are generally performed earlier in childhood to identify and correct vision issues that could impact learning.
Choice D rationale
Scoliosis screening is appropriate for a 10-year-old as it is a crucial period for identifying spinal curvature abnormalities that can develop during rapid growth spurts.
Correct Answer is C
Explanation
Choice A rationale
Allowing an additional 30 minutes of play before bedtime can lead to overstimulation and delay the child's ability to settle down for sleep. Consistent bedtime routines are crucial for
establishing healthy sleep patterns in children.
Choice B rationale
Letting the child sleep in the parent's bed can create dependency and difficulty in establishing the child's own sleep routine and space. This practice can disrupt both the parent's and
child's sleep in the long term.
Choice C rationale
Keeping a night light on provides a sense of security and comfort for a child who may be afraid of the dark. This helps the child feel safe and can ease the transition to bedtime.
Choice D rationale
Staying with the child until they fall asleep, especially if crying, can reinforce the behavior and make it harder for the child to develop self-soothing skills. It can lead to increased
dependency on the parent's presence to fall asleep.