While inspecting a 5-year-old child's ears,the nurse notes that ...

[Ebrown]

While inspecting a 5-year-old child's ears,the nurse notes that the right pinna protrudes outward and that there is a mass behind the right ear.
 
  In light of these findings,the vital-sign parameter that the nurse would be most concerned with would be
  1. temperature.
  2. heart rate.
  3. respirations.
  4. blood pressure.

Question 2

A nurse caring for a 9-year-old notices some swelling in the child's ankles. The nurse presses against the ankle bone for five seconds,then releases the pressure and notices a markedly slow disappearance of the indentation.
 
  Due to these physical findings,the nurse would be most concerned with assessing
  1. skin integrity,especially in the lowerextremities.
  2. urine output.
  3. level of consciousness.
  4. range of motion and ankle mobility.

[matt]

Answer to Question 1

Answer:1
Rationale:Swelling behind an ear could indicate mastoiditis,and the presence of a fever would indicate a higher index of suspicion for this. There could also be changes in other vital-sign parameters,but they would not be specific for the presence of infection.

Answer to Question 2

Answer:2
Rationale:Dependent,pitting edema,especially in the lower extremities,can be a symptom of both kidney and cardiac disorders.Decreases in urine output can also indicate compromise in both the renal and cardiac systems.Changes in level of consciousness,if present,would more than likely be a later effect in this situation. While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity,diagnosing and treating the underlying cause of the edema is most important.