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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Celiac disease is an autoimmune disorder triggered by the ingestion of gluten, a protein found in wheat, barley, and rye. It causes damage to the lining of the small intestine, leading to malabsorption of nutrients. The characteristic symptoms of celiac disease include abdominal distention, underweight or failure to thrive, thin arms and legs, and foul-smelling stools.
intussusception in (option A) is incorrect because it, refers to a condition where a portion of the intestine telescopes into an adjacent section, causing an obstruction. While intussusception can present with symptoms such as abdominal pain, vomiting, and currant jelly-like stools, it is not typically associated with failure to thrive.
imperforate anus, in (option B) is incorrect because it is a congenital condition in which the opening of the anus is blocked or absent. It can cause difficulties with passing stools, but it is not typically associated with failure to thrive or the specific assessment findings described.
irritable bowel syndrome (IBS) in (option D) is incorrect because it, is a chronic disorder of the gastrointestinal tract characterized by recurrent abdominal pain, changes in bowel habits, and bloating. While IBS can cause gastrointestinal symptoms, it is not typically associated with failure to thrive, underweight, or the specific assessment findings mentioned.
Correct Answer is D
Explanation
Tanner staging is a method used to assess and describe the development of secondary sexcharacteristics during puberty. It is primarily focused on the physical changes that occur asindividuals transition from childhood to adulthood. The Tanner scale consists of differentstages(ItoV)that describethedevelopmentofspecificsecondarysexcharacteristicssuchasbreastdevelopment, pubichairgrowth,genital development,and facialhair growth.
Growthhormonesecretionin(optionA)isincorrectbecauseWhilegrowthhormonedoesplay a role in the overall growth and development of individuals during puberty, Tannerstagingdoes not specificallymeasureor assessgrowth hormone secretion.
Hormone levels in (option B) is incorrect because While hormone levels, including sexhormonessuchas estrogenandtestosterone, doplayasignificantrolein thedevelopmentofsecondary sex characteristics, Tanner staging itself does not involve measuring or assessinghormone levels. Hormone levels can be assessed through laboratory testing, but this is aseparateprocess from Tanner staging
Hyperthyroidism in (option C) is incorrect because Hyperthyroidism, on the other hand, is amedical condition characterized by an overactive thyroid gland that produces an excessivenumberofthyroidhormones.Itisnotdirectlyrelatedtothedevelopmentofsecondarysexcharacteristics. Diagnosing hyperthyroidism typically involves assessing symptoms,conductingphysicalexaminations,andperformingspecificbloodteststomeasurethyroidhormone levelsandevaluatethyroidfunction.
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