A 6-year-old patient who has been placed in skeletal traction has pain, edema, and fever.
The nurse should assess which of the following?
Neurologic status
Range of motion of all extremities
Warmth at site of pain
Blood pressure
The Correct Answer is C
In the given scenario, the 6-year-old patient in skeletal traction is experiencing
pain, edema, and fever. These symptoms raise concerns about the possibility of an infection
at the site of traction. In such cases, the nurse should assess for warmth at the site of pain.
Increased warmth can indicate inflammation, which may be associated with infection. This
assessment finding would require further investigation and intervention, such as notifying the
healthcare provider and obtaining appropriate cultures or imaging studies.
Neurologic status in (Option A) is incorrect because assessing neurologic status, is important
but not the priority in this scenario. Neurologic status assessment is typically performed to
evaluate any neurovascular compromise resulting from the traction, but the presence of pain,
edema, and fever suggests a potential infection that requires immediate attention.
Range of motion of all extremities in (Option B) is incorrect because assessing the range of
motion of all extremities, is not directly relevant to the given symptoms and should not take
priority over assessing for warmth at the site of pain.
Blood pressure in (Option D) is incorrect because assessing blood pressure, is not directly
related to the symptoms of pain, edema, and fever in the context of skeletal traction. While
blood pressure is an essential vital sign, it does not provide specific information about the
potential infection at the site of pain in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse's best response to the student nurse regarding why peer relationships become more important during adolescence is option A. Peer relationships become significant during adolescence because they provide adolescents with a sense of belonging. During this developmental stage, adolescents are transitioning from a primary focus on their family to a greater emphasis on peer interactions and social connections. Peer relationships offer a sense of acceptance, support, and identity as adolescents strive to establish their own identities separate from their families.
adolescents dislike their parents in (option B), is not a correct or comprehensive explanation for the increased importance of peer relationships during adolescence. While it is common for parent-child conflicts to arise during this stage, it does not imply that adolescents dislike their parents as a general rule.
suggesting that adolescents no longer need parental control in (option C), is not correct. While adolescents are seeking increased independence and autonomy, they still require parental guidance and support. Parental control and involvement continue to be essential in providing a secure and nurturing environment during adolescence.
They promote a sense of individuality in adolescents in (option D), is incorrect. Peer relationships do contribute to the development of individuality by allowing adolescents to explore their own interests, values, and social roles. However, the primary reason for the increased importance of peer relationships during adolescence is the sense of belonging and social acceptance they provide.
Correct Answer is B
Explanation
Thebehaviourdescribed,wherethechildappearstobestaringinto space,is characteristicof
B.Absenceseizures.
Absence seizures, also known as petit mal seizures, are a type of generalized seizure thatprimarily affects children. These seizures are brief and usually last for a few seconds. Duringan absence seizure, the child may appear to be staring blankly into space, unaware of theirsurroundings.Theymaynot respond to stimuli orengagein anypurposefulactivity.After theseizure ends, the child typically resumes their previous activity without any memory of theseizure.
Atonic seizures in (option A) is incorrect because it involves a sudden loss of muscle tone,leadingtoalimp or "drop"in theperson.
Simple partial seizures in (option C) are focal seizures that affect a specific region of thebrain,causinglocalizedsymptoms suchas twitchingor tinglinginaparticularbodypart.
Tonic-clonic seizures in (option D) also known as grand mal seizures, is incorrect because itinvolves a combination of muscle rigidity (tonic phase) and jerking movements (clonicphase).
Therefore, based on the description provided, the behaviour of staring into space ischaracteristic of B. Absence seizures. It is important for the child to be evaluated by ahealthcare professional for an accurate diagnosis and appropriate management of theirseizures.
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