Author Question: The nurse is taking care of an adolescent who was admitted following an automobile accident. Which ... (Read 53 times)

mspears3 · **on:** Jun 28, 2018

The nurse is taking care of an adolescent who was admitted following an automobile accident. Which of the following should the nurse know in caring for this client?

1. The adolescent's main concern is with death and dying.
2. Adolescents are concerned with privacy and independence.
3. Adolescents have a fear of loss of self-control related to body.
4. Adolescents will experience separation anxiety.

Question 2

The nurse is checking peripheral perfusion to a child's extremity following a cardiac catheterization. If there is adequate peripheral circulation, the nurse would find that the extremity:

1. Has a capillary refill of greater than three seconds.
2. Is warm, with a capillary refill of less than three seconds.
3. Has decreased sensation with a weakened dorsalis pedis pulse.
4. Has a palpable dorsalis pedis pulse but a weak posterior tibial pulse.

AISCAMPING · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

2
Rationale:
1. The major source of stress for hospitalized school-age children is concern with death and dying.
2. The adolescent desires privacy and independence.
3. Preschoolers are fearful of loss of self-control related to the body and emotions, and fear of bodily injury or mutilation.
4. Separation from parents is the major stressor for the toddlers.

Answer to Question 2

2
Rationale 1: If the capillary refill is over three seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate.
Rationale 2: The nurse checks the extremity to determine adequacy of circulation following a cardiac catheterization. An extremity that is warm with capillary refill of less than three seconds has adequate circulation. Other indicators of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate sensation, and pinkness of skin color.
Rationale 3: If the capillary refill is over three seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate.
Rationale 4: If the capillary refill is over three seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate.
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