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 C
Explanation
Choice A rationale
A properly fastened harness and securely anchored car seat are essential for infant safety. This statement indicates correct practice and does not require further teaching.
Choice B rationale
Using an infant model car seat that is securely anchored is appropriate for a 6-month-old infant. This statement is correct and does not indicate a need for further teaching.
Choice C rationale
A front-facing car seat is inappropriate for a 6-month-old infant. Infants should ride in a rear-facing car seat until at least the age of 2 or until they reach the highest weight or height allowed by the car seat manufacturer. This statement indicates a need for further teaching.
Choice D rationale
A rear-facing car seat in the back passenger seat is the safest position for a 6-month-old infant. This statement is correct and does not indicate a need for further teaching.
Correct Answer is A
Explanation
Choice A rationale
Peer pressure is a significant concern during adolescence as individuals seek acceptance and validation from their peers, often engaging in behaviors they might otherwise avoid.
Choice B rationale
Inclusivity refers to ensuring everyone is included and feels welcomed, but it's not a common concern that would make someone engage in risky behavior like vaping.
Choice C rationale
Cold stress is more related to the physical response to cold environments rather than social situations. Adolescents typically experience cold stress due to environmental conditions, not peer interactions.
Choice D rationale
Role confusion, according to Erikson's stages of development, involves uncertainty about one's role and identity, but it doesn't directly explain engaging in risky behaviors due to peer influence.