A nurse is caring for a 9-year-old child at a clinic.The nurse reviews the assessment findings. Exhibits Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. Assessment Respirations easy and unlabored. Abdomen non-distended. Right forearm and fingers are edematous. Ecchymotic area noted on outer aspect of the forearm. Radial pulse +2. Fingers slightly cool to touch. Child can move fingers and reports a mild "tingling" sensation. Child verbalizesa pain level of 4 on a scale of 0 to 10. Multiple areas of bruising are noted on lower extremities in various stages of healing. Vital Signs Temperature 36.8° C (98.2° F) Heart rate 102/min, Respiratory rate 22/min BP 100/60 mm Hg Oxygen saturation 98% on room air

Rationale for Correct Choices: Right forearm and fingers are edematous: Swelling of the forearm and fingers can indicate a possible fracture or soft tissue injury with vascular compromise. Edema in a closed injury raises concern for compartment syndrome, especially when accompanied by other neurovascular changes. Ecchymotic area on outer aspect of forearm: A single bruise near the site of injury is expected after trauma and not alarming by itself. However, the chils is presenting with other multiple injuries, thus need for further assessment. Fingers slightly cool to touch: Cool fingers suggest impaired circulation, possibly due to vascular compression or damage following trauma. It is a potential sign of compromised blood flow that requires immediate evaluation to prevent tissue ischemia. Child reports a mild "tingling" sensation: Paresthesia can signal early nerve compression or involvement, which may progress if not addressed. Combined with swelling and coolness, this finding suggests a risk of compartment syndrome. Pain level of 4/10: Although moderate, a pain level of 4 in a child presenting with multiple injuries warrants further investigations. Multiple areas of bruising in various stages of healing: Bruising at different stages of healing raises concern for non-accidental trauma (child abuse). This pattern is inconsistent with a single fall and warrants immediate follow-up under child protection protocols. Rationale for Incorrect Choices Radial pulse +2: A normal radial pulse suggests adequate arterial blood flow to the extremity. Although useful, this does not exclude compartment syndrome and is not an urgent finding on its own. Respirations easy and unlabored, abdomen nondistended, and stable vital signs: These are all normal findings that indicate no immediate respiratory, gastrointestinal, or hemodynamic distress. They do not warrant urgent intervention at this time. Vital signs: Temperature, blood pressure, respiratory rate and oxygen saturation are all within normal for the child’s age and support physiologic stability, hence no evidence of immediate systemic compromise.