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
A brightly-colored mobile is suitable for infants who are visually stimulated by motion and color but not appropriate for a 4-year-old.
Choice B rationale
A checkerboard and checkers are more suitable for older children or adolescents who have developed advanced cognitive and strategic thinking skills.
Choice C rationale
A 100-piece jigsaw puzzle is also more appropriate for older children or adolescents with well-developed problem-solving and fine motor skills.
Choice D rationale
Hand puppets are suitable for a 4-year-old as they encourage imaginative play, storytelling, and fine motor skill development.
Correct Answer is D
Explanation
Choice A rationale
Punishing a toddler after a tantrum may reinforce negative behavior as the child may seek attention through tantrums.
Choice B rationale
Telling a toddler that tantrums are unacceptable can be difficult for them to understand and may not prevent the behavior.
Choice C rationale
Offering rewards for stopping tantrums can lead to dependency on rewards and doesn't teach appropriate emotional regulation.
Choice D rationale
Ignoring tantrums helps to avoid reinforcing the behavior, teaching the child that tantrums will not gain attention.