On entering the room of a child in Buck traction, the nurse makes all of the following observations. Which observation requires a nursing intervention?
Child's heels are placed firmly against the foot of the bed.
Head of bed is elevated 20 degrees.
Ropes are on pulleys.
Weights are hanging freely.
The Correct Answer is A
A. In Buck traction, the child’s heels should not be pressed against the foot of the bed, as this disrupts the traction force and may lead to skin breakdown or impaired circulation. The body must remain in proper alignment, and the child should be positioned so that traction can pull effectively.
B. Elevating the head of the bed up to 20 degrees is acceptable to promote comfort and prevent respiratory complications without affecting traction.
C. Ropes must be aligned properly on pulleys to ensure smooth traction force. This is a correct observation.
D. Weights should hang freely at all times to maintain consistent traction; this is the correct setup.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While muscles may become painful with disuse, pain is not the most consistent or defining result. The primary issue is loss of elasticity and shortening.
B. Lack of regular stretching and contraction leads to muscle atrophy, shortening, and decreased elasticity, contributing to joint stiffness and reduced range of motion.
C. Muscles do not become longer or remain flexed with inactivity; instead, they typically shorten due to contracture formation.
D. Fibrosis and spasticity are more associated with neurological damage rather than simple disuse.
Correct Answer is A
Explanation
A. The hypoglossal nerve (cranial nerve XII) controls tongue movements, so asking the patient to move the tongue side to side tests its function.
B. Checking air movement through each nostril assesses the olfactory nerve (cranial nerve I).
C. Asking the patient to shrug the shoulders tests the accessory nerve (cranial nerve XI).
D. Asking the patient to wrinkle the forehead tests the facial nerve (cranial nerve VII).
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