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
The most important factor in determining the rate of fluid replacement in a dehydrated child
is urine output. Urine output is a crucial indicator of renal perfusion and hydration status.
Monitoring urine output allows healthcare professionals to assess the child's response to fluid
replacement therapy and adjust the rate accordingly.
The type of dehydration in (Option A) is incorrect. The type of dehydration, is important in
determining the appropriate fluid composition for rehydration but does not directly dictate the
rate of fluid replacement.
The child’s weight in (Option B) is incorrect. The child's weight, is considered when
calculating the maintenance fluid requirements, but it does not solely determine the rate of
fluid replacement for dehydration.
Serum potassium level in (Option D) is incorrect. The serum potassium level, is important to
monitor in a dehydrated child, especially in cases of severe dehydration, as electrolyte
imbalances may occur. However, it is not the most important factor in determining the rate of
fluid replacement. Fluid replacement is primarily guided by assessing the child's hydration
status through parameters such as urine output and clinical assessment.
Correct Answer is C
Explanation
Compartment syndrome is a condition that can occur following an injury, such as a fracture, where there is increased pressure within a closed space (compartment) in the body. In the case of a forearm fracture, swelling and increased pressure within the compartment can lead to compression of the nerves and blood vessels, resulting in symptoms such as pain, numbness, and decreased function of the affected muscles.
The inability to extend the fingers suggests impairment of the extensor muscles, which are innervated by the radial nerve. If the radial nerve is compressed or injured due to compartment syndrome, it can result in a loss of function in the muscles it innervates, leading to the inability to extend the fingers.
damage to the epiphyseal plate in (option A) is incorrect because it, is not related to the inability to extend the fingers. The epiphyseal plate is the growth plate in long bones, and damage to it would typically affect bone growth rather than finger extension.
, stating that it is normal following this type of injury in (option B), is incorrect. Inability to extend the fingers is not a normal or expected finding after a forearm fracture. It suggests a potential complication or underlying issue.
fat embolism in (option D) is incorrect because it, is unlikely to cause an inability to extend the fingers. Fat embolism occurs when fat globules from a broken bone enter the bloodstream and can lead to respiratory and neurological symptoms, but it would not specifically cause an isolated loss of finger extension.
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