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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. “I am going to listen to your heart.”: This is the correct answer. It is a clear, simple statement that informs the child about what is going to happen. It is important to use language that is appropriate for the child’s age and development.
B. “Can I listen to your lungs?”: While this is a polite way to ask for consent, it might confuse a toddler who may not understand what “lungs” are.
C. “I am going to take your blood pressure now.”: This statement might be too complex for a toddler to understand. It’s better to use simpler language.
D. “Can you stand very still while I feel how warm you are?”: This statement might be confusing for a toddler. It’s better to use clear and direct language.
Correct Answer is A
Explanation
Pruritus of the scalp: This is the correct answer. Pruritus, or itching, of the scalp is a common symptom of pediculosis capitis, also known as head lice.
B. Blisters on the scalp: While blisters can occur with various scalp conditions, they are not typically associated with pediculosis capitis.
C. Bald patches on the scalp: Bald patches can be a sign of conditions like alopecia areata or tinea capitis, but they are not typically associated with pediculosis capitis.
D. Dry patches on the scalp: Dry patches can be a sign of conditions like seborrheic dermatitis or psoriasis, but they are not typically associated with pediculosis capitis.
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