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
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.
Correct Answer is A
Explanation
A subdural hematoma is a type of intracranial bleeding that occurs between the dura mater (the
outermost layer of the meninges) and the skull. The dura mater is a tough membrane that covers
and protects the brain. When a subdural hematoma occurs, blood collects between the dura mater
and the skull, resulting in increased pressure on the brain.
Bleeding is generally arterial, and brain compression occurs rapidly in (Option B) is incorrect because
while bleeding in a subdural hematoma can be arterial, it can also be venous. The rate of bleeding
and brain compression can vary depending on the size and severity of the hematoma.
Bleeding occurs between the dura and the cerebrum in (Option C) is incorrect because the bleeding
in a subdural hematoma does not occur between the dura and the cerebrum (the largest part of the
brain). It specifically occurs between the dura and the skull.
The hematoma commonly occurs in the pretemporal region in (Option D) is incorrect because the
location of a subdural hematoma can vary. While pretemporal region is a possible location, subdural
hematomas can occur in different areas of the brain, depending on the site of injury.
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