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
The nurse's best response to the parents of a 10-year-old child newly diagnosed with type 1
diabetes mellitus, who are concerned about the child's continued participation in soccer, is to
reassure them that it is generally safe for the child to play sports such as soccer unless the
weather is too hot.
Regular physical activity, including participation in sports, is generally encouraged for
children with type 1 diabetes as long as certain precautions are taken. It is important for the
child to have a well-managed diabetes management plan in place, which may include
monitoring blood sugar levels before, during, and after physical activity, adjusting insulin
doses as necessary, and having appropriate snacks available to maintain blood sugar levels.
Option B, suggesting the swim team as an alternative to soccer, may be a viable option if the
child or parents prefer swimming or if the child has specific concerns related to soccer.
However, it is not the best response to the parents' concern about the child's continued
participation in soccer.
Option C, recommending an extra carbohydrate snack before soccer practice, is a valid
suggestion to help maintain the child's blood sugar levels during physical activity. However,
it should be part of a comprehensive diabetes management plan and not the sole response to
the parents' concern.
Option D, encouraging intellectual activity rather than participation in sports, is not
appropriate as physical activity is generally beneficial for children with type 1 diabetes, as
long as appropriate precautions are taken.
Correct Answer is A
Explanation
The scenario describes a 14-year-old male who seems to be always eating, but his weight is appropriate for his height. In this case, it is important to reassure the parents that the behaviour may not necessarily be a cause for concern.
Option A provides an accurate response by explaining that for weight gain to occur, the individual would need to consume an excessive number of calories. Since the adolescent's weight is appropriate for his height, it suggests that his caloric intake is likely balanced and not excessive.
suggesting that he is substituting food for unfilled needs in (option B) is incorrect because it, is speculative and may not be accurate without further assessment or evidence. It is important to avoid making assumptions about underlying psychological or emotional reasons for increased eating without more information.
stating that this is normal due to an increase in body mass during this time in (option C) is incorrect because it, is not necessarily applicable to the scenario. While it is true that adolescents experience growth and changes in body composition during this period, it does not directly explain the constant eating behaviour described.
suggesting that this behaviour is abnormal and indicative of possible future obesity in (option D) is incorrect because it, may be premature and unsupported based solely on the information provided. It is essential to avoid making predictions or assumptions about future health outcomes without proper evaluation.
By providing the parents with information about the caloric intake required for weight gain and reassuring them that their son's eating behaviour may be within a normal range, the nurse can address their concerns and provide accurate guidance. If the parents have further concerned or questions, it may be appropriate to refer them to a healthcare provider for a more comprehensive assessment.
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