A nurse is caring for a child who has Legg-Calve-Perthes disease and is in Buck extension traction.
Which of the following actions should the nurse take?
Reposition the child every 2 hr.
Remove the traction boot during baths.
Reduce fluid intake.
Apply antibiotic ointment to pin sites daily.
The Correct Answer is A
The correct answer is choice a. Reposition the child every 2 hr.
Choice A rationale:
Repositioning the child every 2 hours is essential to prevent complications such as pressure ulcers and to promote comfort and circulation.
Choice B rationale:
Removing the traction boot during baths is not recommended as it can disrupt the traction setup and potentially worsen the condition.
Choice C rationale:
Reducing fluid intake is not necessary for managing Legg-Calve-Perthes disease and could lead to dehydration.
Choice D rationale:
Applying antibiotic ointment to pin sites daily is not applicable in this scenario as Buck extension traction typically does not involve pin sites.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This response is appropriate because it informs the parent that the nurse has a legal obligation to report any suspected child abuse.
Choice A is not an answer because it does not address the parent’s concern and instead defers responsibility to the provider.
Choice C is not an answer because it does not provide any information to the parent and instead suggests contacting a supervisor.
Choice D is not an answer because it implies that the decision to report the incident was made by the supervisor and not the nurse.
Correct Answer is D
Explanation
The correct answer is d. Modify the environment.
Rationale for each choice:
Choice a. Improve the client's communication skills.
- Statement:While communication is important,it is not the priority for a child with hemiplegic cerebral palsy.
- Rationale:Hemiplegic cerebral palsy primarily affects motor skills,not communication abilities.While some children with hemiplegic cerebral palsy may have speech difficulties,it is not the most pressing concern in this case.Addressing environmental barriers to promote mobility and independence takes precedence.
Choice b. Provide respite services for the parents.
- Statement:Respite services can provide valuable support for parents,but they are not the priority in this case.
- Rationale:The focus of the care plan should be on the child's immediate needs and safety.Modifying the environment to enhance the child's functional abilities is crucial for their development and well-being.
Choice c. Foster self-care activities.
- Statement:Encouraging self-care is essential,but it requires a supportive environment.
- Rationale:Before promoting self-care activities,the nurse must ensure the child has the necessary accommodations and modifications in place to facilitate independence.
Choice d. Modify the environment.
- Statement:This is the priority goal for a child with hemiplegic cerebral palsy.
- Rationale:Modifying the home environment can significantly improve the child's mobility,safety,and ability to participate in daily activities.Examples of modifications include:
- Installing grab bars in the bathroom
- Widening doorways
- Removing tripping hazards
- Providing adaptive equipment such as special chairs or utensils
- Ensuring adequatelighting
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