A nurse is reinforcing teaching with the parent of a preschooler who has a hip fracture and is in a spica cast. Which of the following findings should the nurse identify as an indication of infection?
Hot spot on the cast
General edema of the toes
Pruritus under the cast
Pain at the fracture site
The Correct Answer is A
A. A hot spot on the cast may indicate localized infection. When the skin underneath the cast becomes infected, it can lead to localized warmth, tenderness, and redness. It is important to promptly assess and address the situation, as infections can progress quickly in these circumstances.
B. General edema of the toes is a common response to immobilization and injury, but it does not specifically indicate infection. It is more likely related to inflammation or impaired circulation from the cast.
C. Pruritus (itching) under the cast can occur due to the skin's reaction to the cast material, dryness, or moisture accumulation, but it is not necessarily an indication of infection.
D. Pain at the fracture site is common and expected as the fracture heals, but it alone is not an indication of infection unless associated with other symptoms like fever, warmth, or drainage.
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Related Questions
Correct Answer is D
Explanation
A. Increased blood pressure is typically not associated with dehydration. In fact, dehydration often causes hypotension or low blood pressure, especially in severe cases.
B. Distended jugular veins are usually a sign of fluid overload or heart failure, not dehydration. In dehydration, the veins may appear flat due to decreased fluid volume.
C. A flat anterior fontanel is generally expected in a well-hydrated child. A sunken fontanel would indicate dehydration in infants and young toddlers.
D. Increased pulse (tachycardia) is a common sign of dehydration. As the body loses fluid, the heart compensates by increasing the heart rate to maintain adequate perfusion of organs.
Correct Answer is A
Explanation
A. This response reassures the child that they are not to blame for the abuse and provides emotional support. It also establishes a sense of safety for the child to express their feelings.
B. Telling the child that they should have spoken up earlier may cause shame or guilt, which can further harm the child’s emotional well-being.
C. Promising not to tell anyone would be unethical because it is necessary to report suspected abuse to the appropriate authorities for the child's safety.
D. While this response acknowledges the injustice of the situation, it doesn't validate the child's feelings of fear or confusion in a way that encourages trust and healing.
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