A nurse is caring for a client who has balanced skeletal traction with a Thomas splint for the treatment of a fracture of the femur. Which of the following actions should the nurse take to prevent skin breakdown?

Apply lotion to the skin around the edges of the splint.

Turn the client every 4 hr.

Pad the top of the splint with protective dressings.

The nurse should apply a footplate to the bed.

Answer and Explanation

The Correct Answer is C

Choice A reason: Applying lotion to the skin around the edges of the splint may increase moisture and friction, which can contribute to skin breakdown. It is better to use protective dressings to reduce friction.

Choice B reason: Turning the client every 4 hours is not frequent enough. Clients in skeletal traction should be repositioned frequently, typically every 2 hours, to prevent pressure ulcers and maintain skin integrity.

Choice C reason: The correct answer is c because padding the top of the splint with protective dressings helps reduce friction and pressure on the skin, preventing skin breakdown and ensuring the client's comfort.

Choice D reason: Applying a footplate to the bed is not directly related to preventing skin breakdown. The primary focus should be on reducing friction and pressure around the splint.

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Correct Answer is B

Explanation

Choice A reason: Brudzinski's sign is an indicator of meningitis, where flexion of the neck causes involuntary flexion of the hips and knees. This sign is not related to hypocalcemia and is more specific to central nervous system infections.

Choice B reason: Chvostek's sign is a clinical sign of hypocalcemia. It is elicited by tapping on the facial nerve in front of the ear, which causes twitching of the facial muscles. This sign indicates neuromuscular irritability due to low calcium levels and is a key indicator for diagnosing hypocalcemia.

Choice C reason: Cullen's sign is a superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. It is associated with acute pancreatitis and intra-abdominal bleeding, not hypocalcemia. Therefore, it is not an appropriate sign to monitor for in clients with hypocalcemia.

Choice D reason: Kernig's sign is another indicator of meningitis. It involves pain and resistance to knee extension when the hip is flexed. Like Brudzinski's sign, it is specific to meningitis and is not related to hypocalcemia. Monitoring for this sign would not be relevant for a client with low calcium levels.

A. A client who has uncontrolled hypertension B. A client who has chronic atrial fibrillation C. A client who has thrombocytopenia D. A client who has an arteriovenous malformation

Correct Answer is B

Explanation

Choice A reason: Uncontrolled hypertension is a significant risk factor for hemorrhagic stroke rather than ischemic embolic stroke. Hypertension can lead to the rupture of blood vessels in the brain, causing bleeding.

Choice B reason: The correct answer is b because chronic atrial fibrillation increases the risk of embolic stroke. In atrial fibrillation, the irregular heartbeat can lead to the formation of blood clots in the atria. These clots can travel to the brain and cause an ischemic stroke by blocking blood flow.

Choice C reason: Thrombocytopenia, characterized by low platelet count, primarily affects clotting and bleeding tendencies rather than directly increasing the risk of embolic stroke. It can, however, complicate the management of stroke due to bleeding risks.

Choice D reason: An arteriovenous malformation (AVM) is a tangle of abnormal blood vessels connecting arteries and veins in the brain. While AVMs can increase the risk of hemorrhagic stroke, they are not typically associated with ischemic embolic stroke.

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A nurse is caring for a client who has balanced skeletal traction with a Thomas splint for the treatment of a fracture of the femur. Which of the following actions should the nurse take to prevent skin breakdown?

Nursing Test Bank

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Correct Answer is B

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A nurse is caring for a client who has balanced skeletal traction with a Thomas splint for the treatment of a fracture of the femur. Which of the following actions should the nurse take to prevent skin breakdown?