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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The adolescent client's symptoms of localized pain, swelling, and tenderness, particularly at night, are suggestive of a malignancy such as osteosarcoma, which is the most common primary bone tumor in children and adolescents.
Radial ossification in the soft tissues is a characteristic finding in osteosarcoma and is indicative of bone production by malignant cells. Other imaging modalities, such as X-rays, computed tomography (CT), and magnetic resonance imaging (MRI), may also reveal osteolytic or osteoblastic lesions in the bone.
Growing pains are a common, benign condition that occur in children and do not typically present with the
symptoms described in the case scenario.
Rhabdomyolysis is a medical emergency that involves the breakdown of skeletal muscle tissue and release of muscle fiber contents into the bloodstream. It can present with muscle pain, swelling, and tenderness, but typically occurs as a result of injury, infection, or drug toxicity.
Hemosiderosis is a rare condition characterized by the accumulation of iron in various tissues, including the liver, spleen, and bone marrow. It may present with symptoms such as fatigue, joint pain, and abdominal pain, but is not typically associated with the symptoms and imaging findings described in the case scenario.
Therefore, the nurse should consider osteosarcoma as the probable cause of the adolescent client's symptoms and imaging findings, and should collaborate with the healthcare team to develop a plan of care for diagnosis and treatment.
Correct Answer is D
Explanation
The nurse should implement the intervention of including the child's toy in the collection of information when the child screams and tries to hide behind the parent, dropping a stuffed toy. This can help engage the child and make them feel more comfortable during the medical history collection process. The other options (A, B, and C) are not appropriate interventions in this situation.
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