A nurse is educating parents about essential dietary modifications for their child, who has recently been diagnosed with celiac disease.

Which foods should the nurse include in the list of permissible foods for this child?

Choice A rationale
When caring for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, the most important intervention for the nurse to implement is monitoring peripheral pulses and sensation in the right leg. This is crucial because the traction places tension on the bones, which can result in nerve or vascular damage. Changes in peripheral pulses and sensation can indicate potential complications, such as compromised blood flow or nerve compression, which need immediate attention to prevent further damage.
Choice B rationale
While cleansing pin sites as prescribed is important for infection prevention, it is not the most critical intervention in the context of assessing vascular and neurologic status.
Choice C rationale
Assessing skin for redness and signs of tissue breakdown is important for skin care and preventing pressure ulcers, but it is secondary to monitoring peripheral pulses and sensations when the child is in traction.
Choice D rationale
Changing position every 2 hours is a standard nursing practice to prevent pressure ulcers and provide comfort, but it does not take precedence over monitoring circulation and sensation in the affected limb.

The correct answer is: C

Choice A reason: Comparing the child’s vital signs over the past three weeks could provide data on any changes in his physical health status. However, without additional context, this information alone may not be sufficient to determine the cause of his symptoms. Vital signs are typically within the following ranges for a healthy 10-year-old: temperature 97.8°F to 99.1°F (36.5°C to 37.3°C), pulse 70 to 110 beats per minute, respirations 17 to 22 breaths per minute, and blood pressure 90/60 mmHg to 120/80 mmHg.

Choice B reason: Counseling the parents to pay more attention to the child might be helpful if the child’s symptoms are due to emotional neglect or lack of parental involvement. However, this intervention assumes that the parents are not attentive without evidence and does not directly address the child’s reported symptoms.

Choice C reason: Asking the boy to describe a typical day at school is a non-invasive way to gather more information about potential stressors or issues that could be contributing to his symptoms. This approach can help identify if the symptoms are related to school environment, bullying, academic pressure, or other psychosocial factors.

Choice D reason: Conducting a complete neurological assessment would be appropriate if there were specific indications of neurological issues. Since the boy’s symptoms are non-specific and could be related to a variety of causes, including stress or anxiety, a neurological assessment might not be the most immediate step without further evidence suggesting a neurological cause.