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 C
Explanation
Hydrocephalus refers to a condition characterized by an abnormal accumulation ofcerebrospinal fluid (CSF) within the ventricles of the brain. In infants, hydrocephalus cancause the head to enlarge rapidly as a result of the increased pressure exerted by theaccumulatingfluid.Thisisknownas"rapidheadgrowth."Theincreasedintracranialpressurecanlead to irritabilityand poorappetite in infants.
The distended scalp veins are another common sign of hydrocephalus. As the fluidaccumulates,itputs pressureon thebloodvessels inthe brain,causingtheveinsin thescalptobecome morevisible and distended.
Cerebral palsy in (option A) is incorrect because is a neurological disorder that affects bodymovementandmusclecoordination,butitdoesnottypicallypresentwithrapid headgrowthordistended scalp veins.
Syndrome of inappropriate antidiuretic hormone (SIADH) in (option B) is incorrect becauseitisacondition characterized byexcessivesecretionofantidiuretichormone,leadingtofluidimbalance, but it does not usually cause rapid head growth or distended scalp veins. Reye'ssyndrome (D) is a rare condition that primarily affects the liver and brain, and it does nottypicallypresent with rapid headgrowthor distended scalp veins.
Therefore, based on the signs described, hydrocephalus (C) is the most likely disorder in thiscase.Itisimportantto seekmedicalattentionpromptlyforaproperdiagnosisand appropriatemanagementofhydrocephalus in infants.
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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