A nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's extension traction. The nurse should include which of the following information in the teaching?
Buck's extension traction will relieve muscle spasms.
Buck's extension traction will allow supported movement of the extremity.
Buck's extension traction will maintain alignment of the pins.
Buck's extension traction will reduce the fracture.
The Correct Answer is A
A. Buck's traction is commonly used to relieve muscle spasms and provide pain relief before surgical repair.
B. It does not allow movement of the extremity but rather limits movement to reduce pain.
C. Buck's traction does not involve pins, so alignment of pins is not relevant.
D. It does not reduce fractures but helps to maintain alignment and comfort until surgery.
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Correct Answer is C
Explanation
A. Checking for fecal impaction can help relieve the cause of autonomic dysreflexia but should be done after positioning the client.
B. Skin breakdown can trigger autonomic dysreflexia, but the immediate priority is to lower blood pressure by sitting the client up.
C. Placing the client in a sitting position helps lower blood pressure, which is the immediate concern in autonomic dysreflexia.
D. Checking for bladder distention is essential to find the trigger, but positioning comes first to manage the acute blood pressure elevation.
Correct Answer is D
Explanation
A. Restlessness may indicate incomplete recovery or inadequate sedation reversal.
B. A brisk response to stimulus suggests the client is still in a mildly sedated state and not fully recovered.
C. A sluggish response to stimulus also indicates the client is not yet fully alert and oriented.
D. The client being cooperative and oriented is an indication of full consciousness and recovery from sedation, meeting discharge criteria.
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