A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be preformed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take?

Notify the health care provider (HCP)

Administer an analgesic

Release the skin traction

Apply ice to the extremity

Answer and Explanation

The Correct Answer is A

A. The absence of the dorsalis pedis pulse in the right foot is concerning and could indicate compromised circulation to the extremity. It is essential to notify the healthcare provider promptly so that further assessment and intervention can be initiated to address the circulation issue and prevent potential complications such as ischemia or tissue damage.

B. Administering an analgesic may be necessary to manage the child's pain, especially if they are experiencing discomfort due to the femur fracture. However, addressing the absent dorsalis pedis pulse takes priority as it suggests a potential vascular problem that requires immediate attention.

C. Releasing the skin traction may not be appropriate at this point without further assessment and guidance from the healthcare provider. Skin traction is often used to temporarily stabilize fractures and reduce pain, and releasing it without proper evaluation could potentially exacerbate the injury or compromise the child's comfort and stability.

D. Applying ice to the extremity is not indicated in this situation. Ice application is typically used for acute injuries to reduce swelling and inflammation, but it is not appropriate when there is concern about compromised circulation.

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Correct Answer is A

Explanation

A. Wheezing, which is a high-pitched whistling sound heard during expiration, is a common symptom of asthma. It occurs due to narrowed airways and airflow obstruction, often in response to triggers such as allergens, respiratory infections, or exercise.

B. Low-grade fever in the afternoon is not typically associated with asthma. Fever is more commonly seen in response to infections, such as respiratory infections, which can exacerbate asthma symptoms but is not a direct manifestation of asthma itself.

C. Without the complete statement, it is difficult to assess its relevance to asthma symptoms. However, an abrupt onset of symptoms, such as sudden shortness of breath or chest tightness, may occur during an asthma attack or exacerbation.

D. Sharp pleuritic pain is not a typical finding in asthma. Pleuritic pain, which is sharp and worsened by breathing, is more commonly associated with conditions affecting the pleura, such as pneumonia or pleurisy.

A. Adduction of the arms at the shoulders B. Abnormal flexion of the upper extremities and extension and adduction of lower extremities C. Flaccid paralysis of all extremities D. Rigid extension and pronation of the arms and legs

Correct Answer is D

Explanation

D. This is the correct characteristic of decerebrate posturing. Decerebrate posturing is characterized by rigid extension and pronation (turning inward) of the arms and legs. It indicates severe neurological dysfunction and increased intracranial pressure, often involving damage to the brainstem.

A. This characteristic is not associated with decerebrate posturing. Adduction refers to movement toward the midline of the body, which is not typically observed in decerebrate posturing.

B. This description is not characteristic of decerebrate posturing. Decerebrate posturing involves extension, not flexion, of the upper extremities, along with extension and pronation (not adduction) of the lower extremities.

C. Flaccid paralysis refers to the absence of muscle tone and movement, which is not characteristic of decerebrate posturing. Decerebrate posturing involves increased muscle tone and abnormal, rigid extension of the arms and legs.

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A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be preformed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a school-age child who has asthma. The nurse should identify which of the following findings?

Correct Answer is A

Explanation

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing?

Correct Answer is D

Explanation

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