A nurse is providing education to a client on how to care for their cast.
Which of the following instructions should the nurse include?
Report any change in the color or temperature of the toes on the casted extremity.
Keep the cast dry and avoid submerging it in water.
Apply lotion or powder to relieve itching under the cast.
Use a warm hair dryer to dry the cast if it gets wet.
Correct Answer : A,B
Choice A rationale
Reporting any change in the color or temperature of the toes on the casted extremity is crucial for detecting potential neurovascular compromise. Changes like pallor, cyanosis, coolness, or increased warmth can indicate impaired circulation, nerve compression, or infection, requiring immediate medical attention to prevent permanent tissue damage or complications.
Choice B rationale
Keeping the cast dry and avoiding submersion in water is essential to maintain the cast's integrity and prevent skin maceration. A wet cast can soften, lose its supportive capabilities, and become a breeding ground for bacteria or mold, leading to skin irritation, infection, or breakdown. Special covers are available for showering.
Choice C rationale
Applying lotion or powder to relieve itching under the cast is contraindicated. Lotions can soften the skin, promoting maceration and fungal growth, while powders can cake and irritate the skin. Inserting objects under the cast can also lead to skin abrasions, infections, or foreign body reactions, compromising skin integrity.
Choice D rationale
Using a warm hair dryer to dry the cast if it gets wet is generally discouraged. While a cool setting might be acceptable for some fiberglass casts, warm or hot air can cause burns to the underlying skin, especially if sensation is impaired or if the cast material is plaster, which can retain heat. Air drying or a fan on a cool setting is preferred.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Ensuring the car seat is securely installed and properly buckled is paramount for infant safety. Correct installation prevents excessive movement of the car seat during a collision, and proper buckling ensures the infant is restrained effectively, reducing the risk of ejection or injury from impact forces.
Choice B rationale
Using an expired car seat or one that has been involved in a previous accident is highly dangerous. Over time, materials degrade, and the structural integrity of a car seat can be compromised after an accident, even if there are no visible signs of damage. Expired seats may not meet current safety standards.
Choice C rationale
Always placing the car seat in the front seat, facing forward, is incorrect and extremely dangerous. The front passenger airbag can deploy with significant force, causing severe or fatal injuries to an infant in a car seat. Infants and young children should always be in the back seat to mitigate this risk.
Choice D rationale
Placing the car seat in the middle of the back seat, facing forward, is incorrect for infants. Infants should always be in a rear-facing car seat until they meet the maximum height or weight limits for their rear-facing car seat, typically around 2 years of age or older. The middle back seat is generally safest for placement due to optimal crash protection.
Correct Answer is D
Explanation
Choice A rationale
Allowing a teenager with suicide ideation to keep personal belongings, especially sharp objects, presents an immediate and significant safety risk. Such items can be readily used for self-harm, undermining the primary goal of ensuring the patient's physical safety in a hospital environment. The environment must be strictly controlled to remove potential means of self-injury.
Choice B rationale
While continuous monitoring is crucial for a teenager with suicide ideation, checking on them every hour is insufficient. The inherent risk of self-harm requires constant, direct observation to intervene immediately if the teenager attempts to harm themselves. Hourly checks leave ample time for potential self-injurious behaviors to occur unsupervised.
Choice C rationale
A no-suicide contract, while sometimes used as a therapeutic tool, does not guarantee that a teenager will not harm themselves. It relies on the patient's commitment, which can be overridden by intense emotional distress or impulsive urges. This intervention should never replace stringent safety measures like continuous supervision and environmental control in an acute setting.
Choice D rationale
Removing any items that could be used for self-harm and providing continuous supervision are essential safety interventions. This creates a secure environment by eliminating immediate means of injury and ensures constant observation, allowing for immediate intervention during an emergent situation. This approach directly mitigates the risk of self-harm in a vulnerable patient.
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