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 A
Explanation
Graves' disease is an autoimmune disorder that affects the thyroid gland and results in the overproduction of thyroid hormones. Treatment for Graves' disease typically involves medications to regulate thyroid function. Adherence to the medication regimen is crucial for managing the disease and controlling symptoms.
By prioritizing the goal of verbalizing the importance of adherence to the medication regimen, the nurse aims to educate the adolescent about the significance of taking medications as prescribed. This education can help the adolescent understand the impact of medication non-adherence on their health and encourage them to actively participate in their treatment.
, developing alternative educational goals in (option B) is incorrect because it, is not directly related to the management of Graves' disease and its treatment.
allowing the adolescent to make decisions about whether or not to take medication in (option C) is incorrect because it, is not appropriate for a condition like Graves' disease where medication adherence is necessary for disease management. In this case, the nurse should focus on providing education and support to help the adolescent understand the importance of medication compliance.
relieving constipation in (option D) is incorrect because it, may be a consideration if constipation is a symptom experienced by the adolescent with Graves' disease. However, it is not the priority nursing goal as compared to ensuring adherence to the medication regimen, which directly addresses the management of Graves' disease.
Correct Answer is B
Explanation
Hypothyroidismreferstoanunderactivethyroid glandthatdoesnotproduceenoughthyroidhormones. In newborns, this condition is known as congenital hypothyroidism. Thesymptoms mentioned—mottled skin, a large fontanel (soft spot on the baby's head), a largetongue,lethargy, anddifficultyfeeding—arecharacteristic ofhypothyroidism inneonates.
Mottledskincanoccur duetodecreasedcirculationandlow bodytemperatureassociatedwith hypothyroidism. A large fontanel and tongue are common physical features seen ininfants with hypothyroidism. Lethargy and poor feeding are also typical signs of thiscondition.
Hypoglycaemia in (option A) is incorrect because it refers to low blood sugar levels andusuallypresentswithdifferent symptomssuchas jitteriness,tremors,and sweating.
Hypocalcaemia in (option C) is incorrect because it is low calcium levels and can manifestwithsymptoms like muscle cramps, twitching,and seizures.
Phenylketonuria (PKU) in (option D) it is incorrect because it is a metabolic disordercharacterized by the inability to metabolize the amino acid phenylalanine, and it typicallypresentswith differentsymptoms such asintellectual disabilityandamustydoorto theskin.
Therefore, based on the symptoms described, hypothyroidism (B) is the most likely disorderinthisneonate. Itisimportanttoconsultahealthcareprofessionalforaproperdiagnosisandappropriatetreatment.
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