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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Psychotherapy for other family members is essential but not the immediate priority.
B. Therapy for the child is beneficial but secondary to ensuring immediate safety.
C. Ensuring the child's safety is the top priority in suspected abuse cases to prevent further harm.
D. Treatment for the mother (e.g., psychiatric care) is necessary but secondary to child protection.
Correct Answer is ["A","B","D"]
Explanation
A. Giving short and clear explanations helps the child focus on instructions and minimizes confusion.
B. Being fair but firm and sticking to rules provides consistency, which is beneficial for children with ADHD.
C. Observing for medication side effects is important but is not a behavior modification strategy.
D. Providing a structured environment reduces distractions and helps the child feel more secure.
E. Waiting to punish is ineffective for behavior modification, as immediate feedback is more effective.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.