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 B
Explanation
These symptoms are indicative of hypoglycaemia, which occurs when the blood sugar levels drop too low. Providing a source of fast-acting carbohydrates, such as orange juice, can quickly raise the child's blood sugar levels and alleviate the symptoms.
Administering insulin (Option A) is incorrect because it is not appropriate in this situation because it would further lower the child's blood sugar levels.
Offering water (Option C) is incorrect because it would not effectively address the low blood sugar.
Glucagon (Option D) is incorrect because it is typically used in severe cases of hypoglycaemia when the child is unconscious or unable to swallow, and it requires a prescription. In this case, providing orange juice is the safest and most appropriate initial intervention. However, it is important to seek medical attention and inform the child's healthcare provider about the incident.
Correct Answer is C
Explanation
Epispadias is a congenital condition in which the urethral opening is not located at the tip of the penis as is typical but rather along the ventral surface (underside) of the penis. In severe cases, the urethral opening may extend all the way to the bladder.
absence of a urethral opening in (option A) is incorrect because it, describes a condition called urethral agenesis or aplasia, where the urethral opening is completely absent. This is a different condition from epispadias.
a penis shorter than usual for age, in (option B) is incorrect because it is not specific to epispadias and could be caused by various factors unrelated to the condition.
a urethral opening along the dorsal surface (topside) of the penis in (option D) is incorrect because it, is a condition called hypospadias. Hypospadias is another congenital anomaly where the urethral opening is located on the underside or along the ventral surface of the penis, but it is not synonymous with epispadias.
Therefore, epispadias specifically refers to the urethral opening being situated along the ventral surface of the penis.
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