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
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.
Correct Answer is B
Explanation
Choice A rationale
Distracting the child by buying a toy can reinforce the tantrum behavior by teaching the child that tantrums result in rewards. This can lead to an increase in tantrum frequency as the child learns to manipulate situations to get new toys or other desired items.
Choice B rationale
Appearing to ignore the child during a tantrum helps to extinguish the behavior over time. By not giving attention to the tantrum, the child learns that this behavior does not achieve their desired outcome. Consistency is key in this approach to ensure the child understands that tantrums are ineffective.
Choice C rationale
Placing the child in time-out for 3 minutes can be effective in some cases, but it may not be the first recommendation. Time-out removes the child from a stimulating environment and gives them time to calm down. However, it may not address the underlying reasons for the tantrum.
Choice D rationale
Calmly telling the child to stop might not be effective during the peak of a tantrum. Toddlers in the midst of a tantrum often cannot process verbal instructions or reasoning, so this approach may not achieve the desired result.