The nurse is continuing to care for the adolescent.
Admission Assessment
1400:
Adolescent brought to emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.
Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.
Which of the following prescriptions should the nurse anticipate from the provider?
Elevate the right leg above heart level.
Prepare the adolescent for surgery.
Remove the splint.
Apply ice to the affected extremity.
The Correct Answer is B
A. Elevate the right leg above heart level. This is contraindicated for the adolescent because elevating the leg above heart level can increase blood pressure in the injured area and worsen bleeding and swelling.
B. Prepare the adolescent for surgery. This is anticipated for the adolescent because they have an open fracture with bone displacement, which requires surgical intervention to reduce the risk of infection and complications.
C. Remove the splint. This is contraindicated for the adolescent because removing the splint can cause further damage to the bone and soft tissues and increase pain and bleeding.
D. Apply ice to the affected extremity. This is contraindicated for the adolescent because applying ice can decrease blood flow to the injured area and impair healing and sensation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
An oil retention enema is used to soften the stool and lubricate the rectum, making it easier to pass the
stool. It is usually oil-based and contains 90-120 ml of solution.
The temperature of the enema solution affects the effectiveness and comfort of the procedure. If the solution is too hot or cold, it can cause pain, cramps, or damage to the rectal tissue. If the solution is too warm, it can also stimulate peristalsis and cause the client to expel the enema before it has time to work.
The ideal temperature for an enema solution is close to the client's body temperature, which is around 98°F or 36°C. This temperature ensures that the solution is comfortable and does not cause adverse reactions .
Correct Answer is A
Explanation
Correct answer: A. Have the child take a tub bath each morning
A. Have the child take a tub bath each morning: Warm tub baths are recommended for children with juvenile idiopathic arthritis (JIA) as they help to relieve joint stiffness and pain, especially in the morning. The warm water can soothe the joints, making movement easier and reducing discomfort throughout the day.
B. Apply splints to the child's extremities during the day: While splints may be used in JIA, they are typically applied during the night (resting splints) to maintain joint position and prevent contractures. Daytime use of splints (working splints) may be considered in certain situations, but generally, children are encouraged to be as active as possible during the day to maintain joint mobility.
C. Encourage the child to take naps during the day: While rest is important, encouraging too much rest during the day may contribute to joint stiffness. Regular activity helps maintain joint function and mobility, which is essential in managing JIA.
D. Keep the child on bedrest as long as pain persists: Prolonged bedrest is not recommended for children with JIA. It can lead to muscle atrophy, increased stiffness, and reduced joint mobility. Instead, the focus should be on maintaining activity within the child's pain tolerance and using pain management strategies.
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