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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is "{\"xRanges\":[93.828125,113.828125],\"yRanges\":[223,243]}"
Explanation
A. Lateral aspect: The preferred location for performing a heel stick on a neonate is the lateral (outer) aspect of the heel, avoiding the central area and the arch of the foot. This area contains fewer nerve endings and less tissue, making it safer and less painful for the infant. It also minimizes the risk of injury to the underlying bones, blood vessels, and nerves.
B. Heel: The heel is not recommended as a puncture site because it contains fat, bone, and nerves, and puncturing the heel could cause injury or complications such as osteochondritis (bone infection). This site also carries a higher risk of injury to blood vessels and tendons.
C. Medial aspect: The medial (inner) aspect of the heel is also not recommended because it is near the medial plantar artery and nerves. Puncturing this area could result in damage to these structures, leading to complications. The lateral aspect is a safer, preferred location.
Correct Answer is A
Explanation
A. The new onset of lethargy in a child with endocarditis is a significant concern, as it can indicate worsening infection or complications such as embolism. This child requires urgent assessment to prevent further deterioration.
B. Erythema of the lips in a child with Kawasaki disease is concerning, but this symptom is expected as part of the disease process. However, other signs like fever and conjunctivitis would be more concerning.
C. An increased erythrocyte sedimentation rate (ESR) in a child with rheumatic fever suggests inflammation, but it is not an immediate life-threatening concern like the lethargy in endocarditis.
D. Weak pedal pulses in a toddler with coarctation of the aorta indicate circulatory compromise, but this child may not be in immediate danger as the condition is often diagnosed and managed with interventions like surgery or medication.
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