A nurse is developing a plan of care for a child who is in skeletal traction following a femur fracture. Which of the following actions should the nurse include in the plan?
Lift the traction weights when repositioning the child in bed.
Have the child rate their level of pain ever-8 hr.
Monitor the neurovascular status of the child's lower extremities every 12 hr.
Educate the child's guardians about pin site care prior to discharge.
The Correct Answer is D
A. Lift the traction weights when repositioning the child in bed.
This action should not be included in the plan of care because lifting the traction weights can interfere with the traction's effectiveness and potentially cause harm or injury to the child. The weights are specifically calibrated to provide the necessary tension for the traction to stabilize the fracture site.
B. Have the child rate their level of pain every 8 hours.
While pain assessment is an essential component of nursing care, the frequency of every 8 hours may not be sufficient, especially for a child in skeletal traction. Pain management should be more frequent and individualized based on the child's needs, which may vary throughout the day.
C. Monitor the neurovascular status of the child's lower extremities every 12 hours.
Neurovascular assessment is crucial for patients in traction to detect any signs of compromised circulation or nerve function. However, every 12 hours may not be frequent enough to promptly identify changes in neurovascular status. More frequent assessments, such as every 1-2 hours initially and then gradually decreasing based on stability, are typically recommended.
D. Educate the child's guardians about pin site care prior to discharge.
This is the correct answer. Educating the child's guardians about pin site care is essential to prevent infection and other complications associated with skeletal traction. Proper care of the pin sites reduces the risk of infection, which can lead to serious complications such as osteomyelitis. Providing education prior to discharge ensures that the guardians are equipped with the necessary knowledge and skills to care for the child at home effectively.
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Related Questions
Correct Answer is D
Explanation
A. "I'll replace the batteries every 2 weeks." - This statement is incorrect. While it's essential to replace hearing aid batteries regularly, the frequency of battery replacement depends on factors such as battery type, usage, and the specific needs of the individual. Providing a specific timeframe like "every 2 weeks" may not be accurate for all clients.
B. "I'll use isopropyl alcohol to clean my hearing aids." - This statement is incorrect. Isopropyl alcohol can damage hearing aids as it may degrade plastic components or affect the adhesives used in their construction. Instead, clients should use a soft, dry cloth or a specialized hearing aid cleaning tool recommended by their audiologist.
C. "I'll clean my ear with cotton swabs before I insert my hearing aids." - This statement is incorrect. Using cotton swabs to clean the ear canal can push earwax deeper into the ear canal, potentially impacting it and interfering with hearing aid function. Clients should avoid inserting anything into their ear canal and consult with their healthcare provider if earwax buildup is a concern.
D. "It will disconnect the battery when I remove my hearing aids." - This statement is correct. Many behind-the-ear (BTE) hearing aids are designed to disconnect the battery when removed from the ear, helping to conserve battery life when not in use. This understanding indicates that the client grasps an essential aspect of caring for their hearing aids.
Correct Answer is D
Explanation
A. Insomnia: While insomnia can be a side effect of sertraline, it is not typically associated with serotonin syndrome. However, if the insomnia is severe or accompanied by other symptoms of serotonin syndrome, it should be reported to the healthcare provider.
B. Constipation: Constipation is a common side effect of sertraline but is not indicative of serotonin syndrome. It is important to monitor for constipation and manage it appropriately but not as an indicator of serotonin syndrome.
C. Dry mouth: Dry mouth is another common side effect of sertraline but is not specific to serotonin syndrome. While uncomfortable, it does not typically require immediate reporting unless severe or accompanied by other concerning symptoms.
D. Excessive sweating: Excessive sweating, also known as diaphoresis, is a hallmark symptom of serotonin syndrome. It is a significant indicator of serotonin toxicity and should be reported immediately to the healthcare provider for further evaluation and management.
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