nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following actions is best for the nurse to take?
Perform a neurovascular assessment.
Provide reassurance to the client and parents.
Apply an ice pack to the casted leg.
Explain the discharge instructions to the client and parents.
The Correct Answer is A
A. Perform a neurovascular assessment: This is the correct answer. After a cast is applied, it’s crucial to regularly assess the client’s neurovascular status (sensation, movement, temperature, color, and capillary refill) to ensure that the cast is not too tight and that circulation is not compromised.
B. Provide reassurance to the client and parents: While this is important, the immediate priority is to ensure the client’s physical well-being.
C. Apply an ice pack to the casted leg: This can help reduce swelling and pain, but it’s not the immediate priority. The nurse first needs to ensure that the cast is not compromising circulation or nerve function.
D. Explain the discharge instructions to the client and parents: This is typically done later, closer to the time of discharge. The immediate priority is to assess the client’s physical condition.
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Related Questions
Correct Answer is D
Explanation
A. Muscular dystrophy: This is a group of diseases that cause progressive weakness and loss of muscle mass. It’s not a neural tube defect.
B. Cerebral palsy: This is a group of disorders that affect a person’s ability to move and maintain balance and posture. It’s not a neural tube defect.
C. Hydrocephalus: This is a condition that occurs when fluid builds up in the skull and causes the brain to swell. It’s not a neural tube defect, but it can occur as a complication of spina bifida.
D. Spina bifida: This is the correct answer. Spina bifida is a neural tube defect that occurs when the spine and spinal cord don’t form properly. This is a condition that is present at birth (congenital).
Correct Answer is A
Explanation
A. Provide a latex-free environment: This is the correct answer. Many individuals with spina bifida have a latex allergy, so it’s important to provide a latex-free environment to prevent an allergic reaction.
B. Limit visitors to immediate family members: While limiting visitors can help reduce the risk of infection, it is not specific to the care of an infant with spina bifida undergoing surgical closure of the myelomeningocele sac.
C. Initiate contact precautions: Unless the infant has a specific infection that requires contact precautions, this is not typically necessary for a child with spina bifida.
D. Maintain the infant in the supine position: After surgery to close a myelomeningocele, the infant is often positioned prone (on their stomach) to prevent pressure on the surgical site. Therefore, maintaining the infant in the supine position (on their back) is not typically recommended.
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