A 6-year-old patient who has been placed in skeletal traction has pain, edema, and fever.
The nurse should assess which of the following?
Neurologic status
Range of motion of all extremities
Warmth at site of pain
Blood pressure
The Correct Answer is C
In the given scenario, the 6-year-old patient in skeletal traction is experiencing
pain, edema, and fever. These symptoms raise concerns about the possibility of an infection
at the site of traction. In such cases, the nurse should assess for warmth at the site of pain.
Increased warmth can indicate inflammation, which may be associated with infection. This
assessment finding would require further investigation and intervention, such as notifying the
healthcare provider and obtaining appropriate cultures or imaging studies.
Neurologic status in (Option A) is incorrect because assessing neurologic status, is important
but not the priority in this scenario. Neurologic status assessment is typically performed to
evaluate any neurovascular compromise resulting from the traction, but the presence of pain,
edema, and fever suggests a potential infection that requires immediate attention.
Range of motion of all extremities in (Option B) is incorrect because assessing the range of
motion of all extremities, is not directly relevant to the given symptoms and should not take
priority over assessing for warmth at the site of pain.
Blood pressure in (Option D) is incorrect because assessing blood pressure, is not directly
related to the symptoms of pain, edema, and fever in the context of skeletal traction. While
blood pressure is an essential vital sign, it does not provide specific information about the
potential infection at the site of pain in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Hypoglycaemia is characterized by low blood sugar levels. In children, symptoms of hypoglycaemia can vary, but irritability is a common sign. Other signs and symptoms of hypoglycaemia in children may include sweating, trembling, pale skin, hunger, weakness, confusion, and dizziness.
Normal sensorium and serum glucose greater than 160 mg/dL in (Option A) is incorrect because a normal sensorium (normal level of consciousness) and a serum glucose level greater than 160 mg/dL would not be indicative of hypoglycaemia.
Urine positive for ketones and serum glucose greater than 300 mg/dL in (Option B) is incorrect because it describes characteristics of hyperglycaemia (high blood sugar levels) rather than hypoglycaemia. Positive urine ketones and a serum glucose level greater than 300 mg/dL are commonly seen in diabetic ketoacidosis, a complication of high blood sugar levels in diabetes.
Increased urination and serum glucose less than 120 mg/dL in (Option D) is incorrect because it describes increased urination and a serum glucose level less than 120 mg/dL. While a serum glucose level less than 120 mg/dL could indicate hypoglycaemia, increased urination is not a typical sign of hypoglycaemia. Increased urination may be seen in conditions such as diabetes mellitus when blood sugar levels are consistently high.
Correct Answer is B
Explanation
The term used to describe an abnormally increased convex angulation in the curvature of the thoracic spine, which appears as a "hump back" or rounded upper back, is kyphosis.
Kyphosis refers to an excessive forward rounding or curvature of the thoracic spine, leading to a visible hump-like appearance. It can result from various causes, including poor posture, congenital abnormalities, osteoporosis, or certain medical conditions.
ankylosis in (option A), refers to the abnormal fusion or immobility of a joint, typically due to inflammation or injury.
Lordosis, in (option C) refers to an excessive inward curvature of the lower back, causing the abdomen and buttocks to protrude.
, scoliosis in (option D), refers to an abnormal sideways curvature of the spine, typically in an "S" or "C" shape. It is different from kyphosis, which primarily affects the thoracic spine and results in a rounded upper back.
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