A nurse is caring for a 9-year-old client at a clinic. Exhibits The nurse reviews the assessment findings. 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 nondistended. 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 verbalizes a pain level of 4 on a scale of 0 to 10. Multiple areas of bruising noted on lower extremities in various stages of healing. Exhibit 3 Vital Signs 1000: Temperature 36.80 C (98.20 F) Heart rate 102/min Respiratory rate 22/min BP 100/60 mm Hg Oxygen saturation 98% on room air
Explanation & Rationale
Findings Requiring Immediate Follow-Up Right forearm and fingers are edematous: Swelling after trauma can indicate a fracture, soft tissue injury, or early compartment syndrome. Edema can compromise circulation and should be assessed promptly. Fingers slightly cool to touch: Cool fingers may indicate reduced perfusion to the extremity, which is concerning after trauma. Immediate assessment of capillary refill, color, and temperature is necessary. Child verbalizes a pain level of 4/10: Pain in children, even moderate, requires attention because it can indicate significant underlying injury and may escalate. Pain assessment and management should be prioritized. Child can move fingers and reports a mild "tingling" sensation: Tingling may indicate nerve involvement or early neurovascular compromise, even if movement is preserved. Timely evaluation is essential. Findings Not Requiring Immediate Follow-Up Radial pulse +2: A +2 radial pulse is normal and indicates adequate arterial flow, so it does not require immediate intervention. Multiple areas of bruising noted on lower extremities in various stages of healing: In this scenario, the bruising is assumed to be from normal childhood activity or minor trauma. It does not automatically signify abuse and is not an urgent concern. Heart rate 102/min: Slightly elevated heart rate may reflect pain or stress. It is within normal limits for a 9-year-old (70–120/min). Respiratory rate 22/min: Within normal range for a 9-year-old (18–26/min) and not urgent.