A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?

Remove one of the weights.

Tie knots in the ropes near the pulleys to shorten them.

Pull the client up in bed.

Increase the elevation of the affected extremity.

Answer and Explanation

The Correct Answer is C

A. Remove one of the weights:
Removing a weight from skeletal traction can compromise the effectiveness of the traction, potentially leading to improper alignment and healing of the fracture. The weights are essential for maintaining the proper alignment and stability of the fractured bone, so altering them without proper medical guidance is not advisable.

B. Tie knots in the ropes near the pulleys to shorten them:
Tying knots in the ropes to shorten them is not a safe or appropriate method for adjusting traction. It can lead to uneven force distribution, poor alignment, and potential injury. Traction adjustments should be made by qualified personnel using proper equipment and methods.

C. Pull the client up in bed:
Pulling the client up in bed helps to ensure that the weights are properly suspended and not resting on the floor. This action helps maintain the effectiveness of the skeletal traction by ensuring that the appropriate amount of force is applied to the fracture. It also prevents potential complications associated with improperly positioned weights.

D. Increase the elevation of the affected extremity:
Increasing the elevation of the affected extremity might be indicated to reduce swelling or improve comfort but does not address the issue of weights resting on the floor. Proper positioning of the weights is crucial for effective traction and must be corrected to ensure optimal treatment outcomes.

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Correct Answer is B

Explanation

A) "I have difficulty swallowing food":
Difficulty swallowing food is a common issue in myasthenia gravis and often requires evaluation by a speech therapist rather than an occupational therapist. This condition can lead to aspiration and nutritional challenges, so a speech therapist is typically involved to address swallowing difficulties.

B) "I have a hard time with brushing my hair":
Struggles with tasks such as brushing hair indicate a need for occupational therapy. Occupational therapists specialize in helping clients with fine motor skills and daily living activities, such as grooming and self-care. This referral would address the client's difficulty in performing these essential tasks.

C) "I've been having problems with bladder control":
Bladder control issues are more related to urological or neurological management rather than occupational therapy. This problem may require evaluation by a urologist or a neurologist who specializes in managing bladder function.

D) "I would rather be in a wheelchair than use a walker to get around":
A preference for mobility aids, such as choosing between a wheelchair and a walker, is a matter of personal choice and mobility management. While an occupational therapist might assist in adapting to and using mobility aids, the statement does not clearly indicate a need for occupational therapy focused on improving specific daily living skills.

A. A client who has a headache following a grade 1 concussion B. A client who has a score of 0 on the NIH Stroke Scale following a transient ischemic attack C. A client who has experienced brain death and is awaiting organ procurement D. A client who has a score of 10 on the Glasgow Coma Scale following a motor vehicle crash

Correct Answer is D

Explanation

A) A client who has a headache following a grade 1 concussion:
A headache following a grade 1 concussion usually indicates a mild injury. Although the client may need monitoring, they are not typically at high risk for rapid deterioration that would necessitate proximity to the nurses' station.

B) A client who has a score of 0 on the NIH Stroke Scale following a transient ischemic attack:
A score of 0 on the NIH Stroke Scale indicates no symptoms of stroke. While close monitoring is important after a transient ischemic attack, this client’s condition is stable, and they might not need to be in the room closest to the nurses' station.

C) A client who has experienced brain death and is awaiting organ procurement:
A client who has experienced brain death is typically stable in terms of neurological status, although they may require monitoring for other reasons. However, their neurological condition would not require immediate proximity to the nurses' station compared to more acute conditions.

D) A client who has a score of 10 on the Glasgow Coma Scale following a motor vehicle crash:
A score of 10 on the Glasgow Coma Scale indicates moderate to severe impairment of consciousness, which suggests a higher risk of rapid deterioration. This client should be placed in the room closest to the nurses' station for continuous monitoring and immediate intervention if needed.

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A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?

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