A nurse is caring for a child who has a hip spica cast. Which of the following actions should the nurse take?
Place the child in a semi-sitting position for meals.
Maintain the child’s lower extremities in a dependent position.
Provide a bedside commode for toileting.
Turn the child every 2 hours.
The Correct Answer is D
Choice A reason: A semi-sitting position for meals is impractical in a hip spica cast, risking discomfort or aspiration; turning every 2 hours prevents pressure injuries. Assuming semi-sitting is correct risks complications, critical to avoid in ensuring safe positioning and care for children in spica casts.
Choice B reason: Maintaining dependent lower extremities increases edema risk in a hip spica cast; turning every 2 hours promotes circulation. Assuming dependent positioning is correct risks swelling, critical to prevent in ensuring proper cast care and comfort for children with hip spica casts.
Choice C reason: A bedside commode is unsuitable for a hip spica cast, which covers the pelvis; bedpans are used. Turning every 2 hours is key. Assuming a commode is appropriate risks impracticality, critical to avoid in ensuring proper toileting and care in spica cast management.
Choice D reason: Turning every 2 hours prevents pressure ulcers and promotes circulation in a child with a hip spica cast, critical for skin integrity and comfort. This ensures proper cast care, reducing complications, supporting healing, and maintaining safety in pediatric orthopedic management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Aspirin is contraindicated in peptic ulcer disease due to its antiplatelet and gastric irritant effects, risking bleeding or ulcer exacerbation. Acetaminophen is safer. Administering aspirin risks gastrointestinal hemorrhage, critical to avoid in ensuring safe pain management for clients with a history of peptic ulcers.
Choice B reason: Ibuprofen, an NSAID, irritates the gastric mucosa, worsening peptic ulcers and increasing bleeding risk, making it unsuitable. Acetaminophen is preferred. Administering ibuprofen risks ulcer perforation or bleeding, critical to prevent in ensuring safe headache relief for clients with a peptic ulcer history.
Choice C reason: Ketorolac, an NSAID, is contraindicated in peptic ulcer disease due to its potent gastric irritant effects, risking ulcer aggravation or bleeding. Acetaminophen is safe. Administering ketorolac risks severe gastrointestinal complications, critical to avoid in providing safe pain management for clients with peptic ulcer history.
Choice D reason: Acetaminophen is safe for headache relief in peptic ulcer clients, lacking gastric irritant effects, avoiding risks of bleeding or ulcer worsening. Administering it ensures effective pain management, critical for client comfort, preventing gastrointestinal complications, and supporting safe care in clients with a history of peptic ulcers.
Correct Answer is B
Explanation
Choice A reason: Ignoring the nurse reflects avoidance, not rationalization, where clients justify behaviors, like blaming a partner. Assuming ignoring is rationalization risks misidentifying coping, potentially missing stress management needs, critical to avoid in supporting clients with chronic stress diagnoses.
Choice B reason: Stating behavior is due to a partner’s actions is rationalization, justifying stress responses to avoid responsibility. Recognizing this is critical for addressing maladaptive coping, guiding therapeutic interventions, and supporting healthier stress management strategies in clients with chronic stress diagnoses.
Choice C reason: Refusing treatment reflects denial, not rationalization, where clients provide excuses like blaming others. Assuming refusal is rationalization risks misinterpreting coping, potentially delaying intervention, critical to prevent in addressing chronic stress and promoting treatment acceptance in clients.
Choice D reason: Frequent calls reflect anxiety or dependency, not rationalization, where clients justify behaviors, like blaming others. Assuming calls are rationalization risks missing emotional needs, critical to avoid in ensuring proper stress management and support for clients with chronic stress diagnoses.
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