A nurse is caring for a child who has Legg-Calve-Perthes disease and is in Buck extension traction.
Which of the following actions should the nurse take?
Reposition the child every 2 hr.
Remove the traction boot during baths.
Reduce fluid intake.
Apply antibiotic ointment to pin sites daily.
The Correct Answer is A
The correct answer is choice a. Reposition the child every 2 hr.
Choice A rationale:
Repositioning the child every 2 hours is essential to prevent complications such as pressure ulcers and to promote comfort and circulation.
Choice B rationale:
Removing the traction boot during baths is not recommended as it can disrupt the traction setup and potentially worsen the condition.
Choice C rationale:
Reducing fluid intake is not necessary for managing Legg-Calve-Perthes disease and could lead to dehydration.
Choice D rationale:
Applying antibiotic ointment to pin sites daily is not applicable in this scenario as Buck extension traction typically does not involve pin sites.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a.While involving mental health professionals can be part of a broader intervention plan, it is not the immediate priority in cases of suspected abuse. The nurse must first address the immediate safety concerns and follow the required reporting procedures.
b.Separating the child from the parents without proper authority or immediate threat can escalate the situation and may not be legally permissible. This action should be taken by authorities with the legal power to do so if deemed necessary.
c.Nurses are mandated reporters, which means they are legally required to report any suspected child abuse to the appropriate authorities immediately. This action ensures that the child’s safety is prioritized and that a proper investigation can be initiated however,obtaining a detailed history is the priority.
d.When a nurse observes several bruises on a child, the initial action should be toobtain a detailed history. This step allows the nurse to gather information about the circumstances surrounding the bruises, assess for any potential signs of abuse, and determine the most appropriate course of action.
Correct Answer is A
Explanation
Adolescents affected by scoliosis often experience body image dissatisfaction.
Therefore, the nurse should anticipate body image changes as the most common reaction.
Choice B is not correct because loss of privacy is not the most common reaction
when dealing with scoliosis surgery.
Choice C is not correct because feelings of displacement are not the most
common reaction when dealing with scoliosis surgery.
Choice D is not correct because identity crisis is not the most common reaction
when dealing with scoliosis surgery.
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