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 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.
Correct Answer is B
Explanation
Choice A rationale
Soda and high quantities of juice are high in sugar and lack essential nutrients, making them poor beverage choices for a toddler.
Choice B rationale
Milk provides essential nutrients like calcium and vitamin D, while limiting juice intake reduces sugar consumption, promoting better overall health.
Choice C rationale
Gatorade is designed for athletes to replenish electrolytes and contains high levels of sugar and artificial ingredients, not suitable for toddlers.
Choice D rationale
Red Bull, an energy drink, is highly inappropriate for children due to its high caffeine content and potential harmful health effects.