The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse monitors for the most serious complication associated with this type of traction by checking for which?

An increase in the blood pressure

An elevated temperature

A decrease in urine output

A lack of appetite

Answer and Explanation

The Correct Answer is B

B. The most serious complication associated with skeletal traction is osteomyelitis, an infection that involves the bone. This condition can occur when organisms gain access to the bone either systemically or through the openings created by the metal pins or wires used in the traction.

A. Increased blood pressure can occur for various reasons but it is not the most serious complication associated with skeletal traction.

C. A decrease in urine output could indicate systemic infection which is a late feature of osteomyelitis and therefore, not the earliest to monitor.

D. Changes in appetite can occur in response to pain or stress but they are not typically the most serious complication associated with skeletal traction.

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Correct Answer is A

Explanation

A. Prompt initiation of appropriate antibiotics is essential to prevent the spread of infection, alleviate symptoms, and promote healing.

B. Surgical debridement of necrotic tissue is often necessary for treating acute osteomyelitis, especially if there is extensive tissue damage or the formation of abscesses. Surgical intervention aims to remove infected and dead tissue, reduce bacterial load, and promote wound healing.

C. Antipyretic therapy, such as acetaminophen or ibuprofen, may be administered to reduce fever and alleviate associated symptoms in clients with acute osteomyelitis. While fever management is important for comfort and overall well-being, it may not be the immediate priority unless the fever is high or causing significant distress.

D. Adequate nutrition and hydration support immune function, tissue repair, and overall recovery. However, while important for long-term management, optimizing nutrition and hydration may not be the immediate priority unless the client is severely malnourished or dehydrated.

A. Altered blood flow increases cardiac workload with resulting heart failure. B. Inflammation weakens blood vessels, leading to aneurysm. C. Untreated disease causes mitral valve stenosis. D. Increased lipid levels lead to the development of atherosclerosis.

Correct Answer is B

Explanation

B Kawasaki disease primarily affects medium-sized arteries, including the coronary arteries. The inflammation associated with Kawasaki disease can weaken the walls of the blood vessels, leading to the formation of aneurysms, particularly in the coronary arteries. Coronary artery aneurysms are a hallmark complication of Kawasaki disease and can increase the risk of myocardial infarction and other cardiovascular problems.

A This option describes a possible consequence of Kawasaki disease. Kawasaki disease can cause inflammation of the blood vessels, including the coronary arteries, which can lead to the formation of coronary artery aneurysms. These aneurysms can disrupt blood flow to the heart muscle, leading to ischemia and potentially heart failure.

C Mitral valve stenosis is not a typical complication of Kawasaki disease. While Kawasaki disease can affect the cardiovascular system and lead to complications such as coronary artery aneurysms, it does not typically cause mitral valve stenosis.

D Atherosclerosis is not a direct consequence of Kawasaki disease. Kawasaki disease primarily involves inflammation of the blood vessels rather than changes in lipid levels, which are more commonly associated with conditions such as hyperlipidemia or familial hypercholesterolemia.

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The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse monitors for the most serious complication associated with this type of traction by checking for which?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a newly-admitted client who has acute osteomyelitis. Which of the following interventions is the priority for the nurse to implement?

Correct Answer is A

Explanation

The nurse is caring for a child with a diagnosis of Kawasaki disease. The child's parent asks the nurse, "How does Kawasaki disease affect my child's heart and blood vessels?" On what understanding is the nurse's response based?

Correct Answer is B

Explanation

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