A nurse is reinforcing teaching with the parent of a preschooler who has a hip fracture and is in a spica cast.Which of the following findings should the nurse identify as an indication of infection?
Hot spot on the cast.
Pruritus under the cast.
General edema of the toes.
Pain at the fracture site.
The Correct Answer is A
Choice A rationale
A hot spot on the cast indicates localized warmth, which is a common sign of infection. The presence of a hot spot suggests that there might be an underlying infection beneath the cast, potentially requiring medical intervention. It is important to monitor for signs of infection to prevent complications and ensure proper healing of the fracture.
Choice B rationale
Pruritus, or itching, under the cast is a common discomfort experienced by patients with casts. It is usually due to dry skin or irritation but is not typically a sign of infection. While pruritus can be bothersome, it does not indicate an infectious process and can be managed with appropriate skin care.
Choice C rationale
General edema of the toes can occur due to prolonged immobility or dependency of the limb. While it can indicate impaired circulation or venous return, it is not specific to infection. Generalized edema requires monitoring but is not a definitive sign of infection within the cast.
Choice D rationale
Pain at the fracture site is expected after a fracture and can be managed with analgesics and proper cast care. Persistent or worsening pain might indicate complications such as improper cast fit or delayed healing, but it is not a specific sign of infection. Pain management and follow-up are essential for recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["5"]
Explanation
Step 1 is: Convert the child's weight from pounds to kilograms: 33 lb ÷ 2.2 = 15 kg.
Step 2 is: Calculate the total daily dose: 50 mg/kg/day × 15 kg = 750 mg/day.
Step 3 is: Calculate the dose per administration (every 8 hours, which is 3 times a day): 750 mg/day ÷ 3 = 250 mg/dose.
Step 4 is: Determine the volume of medication to administer: 250 mg ÷ (250 mg/5 mL) = 5 mL.
Final calculated answer: 5 mL.
Correct Answer is C
Explanation
Choice A rationale
Telling a child that "This should not have happened to you" acknowledges the injustice of the situation. While this statement can validate the child's feelings, it may not provide the necessary comfort and reassurance that the child needs in the moment.
Choice B rationale
Promising not to tell anyone about the abuse is inappropriate and unethical. As a mandated reporter, the nurse has a legal and ethical obligation to report suspected child abuse to the appropriate authorities. Making such a promise can hinder the necessary investigation and protection of the child.
Choice C rationale
Informing the child that "It is not your fault that this happened" is essential in alleviating feelings of guilt and shame that the child may have. It helps the child understand that they are not to blame for the abuse and that they are not responsible for the actions of the abuser. This reassurance is crucial for the child's emotional healing.
Choice D rationale
Telling the child "You should have told someone about this sooner" can place undue blame and guilt on the child. Children who experience abuse often feel fear, shame, and confusion, which can prevent them from disclosing the abuse. It is important to provide a supportive and non-judgmental environment to encourage the child to share their experiences.
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