A nurse is assisting with the care of an adolescent client who is in skeletal traction for the treatment of a fractured femur. Which of the following actions should the nurse take?

Gently lift the traction weights off the floor when repositioning the client.

Reduce intake of foods containing fiber while nonambulatory.

Perform passive range-of-motion exercises to the affected extremity every 2 hours.

Apply protective padding to the end of the pin sites.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Gently lift the traction weights off the floor when repositioning the client. Rationale: This choice is not recommended in the care of a client in skeletal traction. Traction weights should never be lifted off the floor as they provide the necessary counter traction to align and immobilize the fractured bone. Lifting the weights could disrupt the traction and jeopardize the healing process.
Choice B rationale:
Reduce intake of foods containing fiber while nonambulatory. Rationale: While constipation can be a concern for clients in skeletal traction due to decreased mobility, reducing fiber intake is not the appropriate intervention. Adequate fiber intake is important to promote regular bowel movements and prevent constipation. Hydration and mobility exercises are more suitable approaches to manage constipation.
Choice C rationale:
Perform passive range-of-motion exercises to the affected extremity every 2 hours. Rationale: Passive range-of-motion exercises are important to maintain joint mobility and prevent muscle atrophy in a nonambulatory client. However, performing these exercises every 2 hours might be excessive and could cause unnecessary discomfort for the client. Range-of-motion exercises are usually done every 4 to 8 hours to strike a balance between maintaining joint health and providing rest.
Choice D rationale:
Apply protective padding to the end of the pin sites. Rationale: This is the correct choice. Applying protective padding to the end of the pin sites is crucial to prevent pressure ulcers and infection. The pin sites are potential entry points for bacteria, and protecting them helps reduce the risk of infection. Padding also prevents pressure on the skin and underlying tissues, reducing the potential for pressure injuries.

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Correct Answer is B

Explanation

Choice A rationale:
Avoiding discussions about the child's diagnosis with the sibling might create confusion and anxiety for the sibling. Open communication is essential for helping siblings understand their brother or sister's condition and cope with the changes in the family dynamic.
Choice B rationale:
Encouraging phone calls between the siblings is a positive step in promoting sibling adaptation when one of them has a chronic illness like cystic fibrosis. Maintaining connections through communication helps siblings feel involved, valued, and informed about each other's lives and challenges.
Choice C rationale:
Designating one parent to stay at home with the sibling might lead to feelings of isolation and neglect for the child with cystic fibrosis. Siblings also need support and attention during this time, and isolating one parent could hinder healthy sibling relationships.
Choice D rationale:
Avoiding having the sibling visit the child in the facility may prevent the sibling from understanding the condition and create a sense of fear or confusion. Controlled, supervised visits can actually be beneficial, as they allow the siblings to interact and support each other in a safe environment.

A. Understands that death is permanent. B. Perceives death as a punishment. C. Worries about physical body changes. D. Has feelings of isolation.

Correct Answer is B

Explanation

The correct answer is choiceb. Perceives death as a punishment.

Choice A rationale:

Preschool-aged children generally do not understand that death is permanent.They often view death as temporary or reversible, similar to what they see in cartoons.

Choice B rationale:

Preschoolers may perceive death as a punishment for something they did or thought.This age group often feels guilt and shame, believing their actions or thoughts caused the illness or death.

Choice C rationale:

Worrying about physical body changes is more typical in older children who have a better understanding of the physical aspects of illness and death.

Choice D rationale:

Feelings of isolation are more common in older children and adolescents who are more aware of social dynamics and the implications of their illness.

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A nurse is assisting with the care of an adolescent client who is in skeletal traction for the treatment of a fractured femur. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about sibling adaptation with a parent of a child who has cystic fibrosis. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is caring for a preschooler who is terminally ill. Which of the following reactions to death should the nurse expect?

Correct Answer is B

Explanation

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