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
Introducing well-cooked table foods should begin around 8-10 months of age when the baby is ready for finger foods and has developed better chewing skills.
Choice B rationale
Starting solid foods at 3 months old is too early and can interfere with breastfeeding or formula feeding, increasing the risk of allergies and digestive issues.
Choice C rationale
Cow's milk should not be introduced until 12 months of age, as infants need the nutrients from breast milk or formula during their first year for optimal growth.
Choice D rationale
It is recommended to wait until the baby is at least 6 months old before introducing fruit juice, and even then, it should be given in limited quantities to avoid excessive sugar intake.
Correct Answer is B
Explanation
Choice A rationale
Learning to use creative energies relates to the initiative vs. guilt stage, aimed at preschool children, where they begin asserting power and control over their world through play and social interactions.
Choice B rationale
Defining a sense of self is a task during the identity vs. role confusion stage in adolescence. Adolescents work on discovering who they are by exploring beliefs, values, and goals to create a consistent and unique identity.
Choice C rationale
Building a sense of trust is a task during the trust vs. mistrust stage of infancy. Infants need reliable caregiving to develop trust in their environment and the people around them.
Choice D rationale
Learning to perform tasks independently occurs in the autonomy vs. shame and doubt stage, which is observed in toddlers. This stage is about children gaining confidence in their abilities to perform basic tasks on their own.