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 ["A","B","C","D"]
Explanation
Choice A rationale
Continuous labor support, often provided by doulas or trained birth companions, significantly reduces perceived pain intensity. This is mediated by physiological mechanisms like decreased sympathetic nervous system activation, leading to lower circulating catecholamines, and increased release of endogenous opioids, which naturally mitigate pain signals by binding to mu-opioid receptors in the central nervous system.
Choice B rationale
The presence of a supportive individual during labor fosters a sense of security and control for the birthing person. This psychosocial benefit contributes to a more positive subjective experience, reducing feelings of isolation and fear. Emotional support can lead to increased coping efficacy and a greater sense of satisfaction with the birthing process.
Choice C rationale
Research indicates that continuous labor support is associated with better fetal outcomes, including a reduced incidence of fetal distress and fewer low Apgar scores. This may be attributed to decreased maternal stress hormone levels, which can negatively impact uterine blood flow and oxygen delivery to the fetus, thus promoting a more stable intrauterine environment.
Choice D rationale
Improved client outcomes encompass a range of positive effects, such as reduced rates of medical interventions like epidural anesthesia and cesarean sections. The presence of support often empowers the client to labor more effectively, leading to shorter labor durations and a decreased need for pharmacological pain management, contributing to overall maternal well-being.
Choice E rationale
Increased anxiety is an incorrect benefit. Scientific evidence consistently demonstrates that continuous support during labor actually reduces maternal anxiety and stress levels. The presence of a supportive individual provides emotional reassurance and practical assistance, which helps to alleviate fear and promote a sense of calm during the birthing process.
Correct Answer is B
Explanation
Choice A rationale
Excessive dental caries and enlarged tonsils are more commonly associated with bulimia nervosa due to the repeated exposure of teeth to gastric acid from purging and chronic inflammation of the tonsils. Anorexia nervosa primarily involves severe caloric restriction, leading to different physiological adaptations.
Choice B rationale
Skeletal appearance with lanugo on arms is a classic physical finding supporting anorexia nervosa. The emaciated or skeletal appearance is due to severe caloric restriction and muscle wasting. Lanugo, fine downy hair, develops as the body attempts to conserve heat due to insufficient adipose tissue.
Choice C rationale
Irregular heart rate, specifically bradycardia, is common in anorexia nervosa due to metabolic slowdown. However, heavy menstruation (menorrhagia) is not typical; instead, amenorrhea (absence of menstruation) is a hallmark sign, resulting from hormonal imbalances due to malnutrition and low body fat.
Choice D rationale
Overweight with a puffy face is not indicative of anorexia nervosa. Anorexia nervosa is characterized by an extreme fear of gaining weight and a disturbed body image, leading to self-starvation and significant underweight. A puffy face can be associated with refeeding syndrome or specific medical conditions, not primary anorexia.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.