A 10-year-old child is receiving skeletal traction for a femur fracture and has metal pins inserted through the femur attached to traction weights.
During the morning assessment, the nurse notes slight redness around the pin sites with no drainage.
The child denies pain, and vital signs are stable.
What is the nurse's best action to ensure appropriate pin site care and prevent complications?
Notify the healthcare provider immediately and request antibiotics.
Remove crusting around the pin sites to allow for better drainage.
Cleanse the pin sites using sterile saline and assess for signs of infection.
Document findings as normal and continue routine assessments.
The Correct Answer is C
Choice A rationale
Notifying the healthcare provider immediately and requesting antibiotics is premature. Slight redness around pin sites without drainage or pain, and stable vital signs, does not immediately indicate a significant infection requiring systemic antibiotics. This initial finding warrants a thorough assessment and local care before escalating to medical intervention.
Choice B rationale
Removing crusting around pin sites can be detrimental. Crusting can serve as a protective barrier. Aggressive removal can introduce bacteria into the pin tract, increasing the risk of infection, or cause unnecessary pain and trauma to the delicate healing tissue. Gentle cleansing is preferred over forceful removal of adherent crusts.
Choice C rationale
Cleansing the pin sites using sterile saline and assessing for signs of infection is the best immediate action. Slight redness without drainage is often a normal inflammatory response to the foreign body and movement. Sterile saline effectively cleanses without irritating the tissue, and continued assessment helps monitor for evolving signs like increased redness, purulent drainage, or fever.
Choice D rationale
Documenting findings as normal and continuing routine assessments is insufficient. While slight redness can be normal, it still requires diligent monitoring and appropriate pin site care to prevent potential complications. Assuming normalcy without active intervention like cleansing could allow a minor irritation to progress to a more serious infection. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Excessive dental caries and enlarged tonsils are more commonly associated with bulimia nervosa due to the erosive effects of recurrent vomiting on tooth enamel and compensatory hypertrophy of lymphoid tissue in the pharynx. While indicative of disordered eating, they are not primary physical markers for anorexia nervosa.
Choice B rationale
A skeletal appearance with lanugo on arms is highly indicative of anorexia nervosa. The emaciation results from severe caloric restriction, leading to significant adipose tissue and muscle loss. Lanugo, fine downy hair, develops as a compensatory mechanism to conserve body heat due to the lack of insulating fat.
Choice C rationale
An irregular heart rate, such as bradycardia, is a common finding in anorexia nervosa due to metabolic slowdown and electrolyte imbalances. However, heavy menstruation (menorrhagia) is not typically associated with anorexia; amenorrhea (absence of menstruation) is a classic sign due to hormonal suppression from malnutrition.
Choice D rationale
Being overweight with a puffy face is inconsistent with the diagnostic criteria for anorexia nervosa, which is characterized by significantly low body weight. A puffy face might suggest fluid retention or salivary gland enlargement, which can occur in bulimia, but not typical for anorexia.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
A calm environment in the client's room reduces sensory overstimulation and promotes relaxation. This physiological state minimizes sympathetic nervous system activation, thereby reducing the perception of pain and allowing the client to better cope with labor contractions through a less intense physiological response.
Choice B rationale
Maintaining privacy during labor provides the client with a sense of security and control, which can reduce anxiety and stress. Reduced anxiety can modulate pain perception by decreasing the release of stress hormones, allowing the client to focus on coping mechanisms and relaxation techniques.
Choice C rationale
Effective communication involves clear, empathetic, and supportive dialogue. This fosters trust and provides reassurance, which can significantly lower a client's anxiety levels. Reduced anxiety decreases sympathetic nervous system activation, thereby diminishing the physiological perception of pain and enhancing coping abilities.
Choice D rationale
Continuity of care, where the client interacts with familiar caregivers, builds rapport and trust. This consistent support reduces anxiety and allows the client to feel more comfortable and secure. Lower stress levels minimize the release of pain-potentiating neurochemicals, thereby decreasing the subjective experience of pain during labor.
Choice E rationale
Making choices for the client removes their autonomy and can increase feelings of helplessness and anxiety. This can heighten the perception of pain by activating the sympathetic nervous system and stress responses, counteracting efforts to create a supportive and pain-reducing environment during labor.
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