The home care nurse is assessing a 3 week old child with history of bilateral clubfoot noted at birth. The mother reports that the infant has been increasingly irritable in the last day. Assessment findings include: bilateral leg casts in place, child is irritable; pallor and coolness of left foot is noted. What is the nurse's priority action?

Provide range of motion exercises for both lower extremities

Assess for skin breakdown

Refer child for immediate intervention in Emergency Department

Provide cast care for the infant

Answer and Explanation

The Correct Answer is C

A. Range of motion exercises are not appropriate with casts in place and do not address the urgent symptoms.

B. Assessing for skin breakdown is important but does not address the immediate priority.

C. Pallor and coolness indicate compromised circulation, which requires immediate intervention to prevent tissue damage.

D. Cast care is essential but does not address the urgent vascular concern.

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Correct Answer is A

Explanation

A. Respiratory status is the priority due to the risk of aspiration, chemical pneumonia, or airway swelling, which can be life-threatening.

B. Bowel sounds are relevant but are secondary to airway and respiratory assessment.

C. Burns of the mouth may be present but do not take priority over respiratory assessment.

D. Visual acuity is not an immediate concern in detergent ingestion cases.

A. Administering corticosteroid injections B. Providing hot compresses to affected joints C. Encouraging regular physical activity and exercise D. Limiting movement and activity to prevent joint damage

Correct Answer is C

Explanation

A. Corticosteroid injections are used in severe cases but are not routine for mobility or pain relief in long-term management.

B. Hot compresses can provide temporary pain relief but do not address long-term mobility.

C. Regular physical activity and exercise are essential to maintain joint mobility, muscle strength, and reduce stiffness in juvenile idiopathic arthritis.

D. Limiting movement could lead to joint stiffness and decreased mobility, worsening the condition.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who ingested laundry detergent pods (Tide pods). Which of the following assessments is the nurse's priority?

Correct Answer is A

Explanation

When planning the discharge of a child with juvenile idiopathic arthritis, which intervention should the nurse include in the plan of care to promote joint mobility and reduce pain?

Correct Answer is C

Explanation

A mother is telling the school nurse about her concerns regarding her 13-year-old daughter, who reports headaches. The child's grades have dropped, and the child is sleeping late and going to bed early every night. Which would the nurse identify as the priority?

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

An adolescent client has just been diagnosed with systemic lupus erythematosus (SLE). Following client education about the disease, which statement by the client demonstrates understanding of SLE?

Clinical manifestations of acromegaly include: Choose all that applies: (Select All that Apply.)

Which of the following actions should the nurse take when caring for a child in skeletal traction? (Select All that Apply)

The nurse is teaching a group of parents about signs of depression in adolescents. Which statement by a parent indicates the need for further education?