When providing care for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement?
Change position every 2 hours.
Monitor peripheral pulses and sensation in the right leg.
Cleanse pin sites as prescribed.
Assess skin for redness and signs of tissue breakdown.
The Correct Answer is B
When caring for a child in balanced suspension skeletal traction, the most important intervention for the nurse to implement is monitoring peripheral pulses and sensation in the affected leg to detect any compromise in circulation or nerve function. This is crucial because the traction places tension on the bones, which can result in nerve or vascular damage.
Changing positions every 2 hours is important to prevent pressure injuries, but it is not the most critical intervention.
Cleansing pin sites and assessing skin for redness and signs of tissue breakdown are also important, but they are not as urgent as monitoring peripheral pulses and sensation.
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Related Questions
Correct Answer is A
Explanation
Children with autism spectrum disorder may have difficulty with sensory processing, social interactions, and communication, which can contribute to feeding difficulties and failure to thrive. Providing structured meal times is an important intervention to help establish a routine and promote consistency and predictability.
Structured meal times involve setting a specific time for meals and snacks, providing a calm and quiet environment, and limiting distractions. This can help the child focus on the task of eating and reduce sensory overload that may interfere with feeding. The nurse should also ensure that the child is seated comfortably and at an appropriate height for feeding.
Offering food even if disinterested (B), incorporating play during meals (C), and allowing multiple food choices (D) are not necessarily helpful interventions for a toddler with autism spectrum disorder and failure to thrive. Offering food when the child is not interested may reinforce negative feeding behaviors and can contribute to further feeding difficulties. Incorporating play during meals may distract the child from the task of eating and can be counterproductive. Allowing multiple food choices can be overwhelming for the child and may not promote a consistent and structured feeding routine.
Therefore, the nurse should prioritize providing structured meal times as an important intervention for promoting feeding and growth in a toddler with autism spectrum disorder and failure to thrive.
Correct Answer is A
Explanation
The boy's reported symptoms may indicate stress or anxiety related to his school experience. By asking the boy to describe a typical day at school, the nurse can gather information about the child's interactions with teachers and peers, academic performance, and any other potential sources of stress. This information can be used to develop an appropriate plan of care that addresses the child's emotional and physical needs.
Comparing vital signs or conducting a neurological assessment may not provide useful information in this case, and counseling the parents to pay more attention to the child is not a recommended intervention without first identifying the underlying cause of the child's symptoms.
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