nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following actions is best for the nurse to take?
Perform a neurovascular assessment.
Provide reassurance to the client and parents.
Apply an ice pack to the casted leg.
Explain the discharge instructions to the client and parents.
The Correct Answer is A
A. Perform a neurovascular assessment: This is the correct answer. After a cast is applied, it’s crucial to regularly assess the client’s neurovascular status (sensation, movement, temperature, color, and capillary refill) to ensure that the cast is not too tight and that circulation is not compromised.
B. Provide reassurance to the client and parents: While this is important, the immediate priority is to ensure the client’s physical well-being.
C. Apply an ice pack to the casted leg: This can help reduce swelling and pain, but it’s not the immediate priority. The nurse first needs to ensure that the cast is not compromising circulation or nerve function.
D. Explain the discharge instructions to the client and parents: This is typically done later, closer to the time of discharge. The immediate priority is to assess the client’s physical condition.
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Related Questions
Correct Answer is D
Explanation
A. Increased urine output: This is not typically associated with heart failure. In fact, decreased urine output may occur due to reduced kidney perfusion.
B. Weight loss: While weight loss can occur in heart failure, it’s more common in adults than in children. In children, especially toddlers, weight gain or failure to thrive might be observed due to fluid retention or poor nutrition absorption.
C. Bradycardia: This is not typically a sign of heart failure. In heart failure, the heart rate is often increased (tachycardia) as the heart tries to compensate for its decreased pumping efficiency.
D. Orthopnea: This is the correct answer. Orthopnea, or difficulty breathing when lying flat, is a common symptom of heart failure. It occurs because when the body is in a horizontal position, fluid in the body is redistributed, leading to increased fluid in the lungs and difficulty breathing.
Correct Answer is B
Explanation
Answer: (B) "I will apply heat."
Rationale:
A) "I will elevate the affected part." Elevating the affected part is an appropriate action for controlling a minor bleeding episode. Elevation helps reduce blood flow to the area, minimizing swelling and bleeding.
B) "I will apply heat." Applying heat is not recommended for managing bleeding episodes in hemophilia. Heat can increase blood flow to the affected area, which may worsen bleeding. Instead, applying ice or a cold compress is preferred as it helps constrict blood vessels and reduce bleeding and swelling.
C) "I will compress the site." Applying compression to the site is a correct method for controlling bleeding. Gentle pressure helps reduce blood flow and promotes clot formation, which is crucial in managing bleeding episodes.
D) "I will have my child rest." Encouraging rest is beneficial for a child with hemophilia during a bleeding episode. Resting helps minimize movement and further injury, which can assist in controlling bleeding and promoting recovery.
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