What finding would the nurse assessing the neurovascular status of a child in Russell traction report immediately?
Capillary refill less than 3 seconds
Ability to wiggle toes
Skin that's warm to the touch
Bluish coloration of skin
The Correct Answer is D
A. Capillary refill less than 3 seconds is normal and indicates good perfusion.
B. Ability to wiggle toes indicates intact motor function.
C. Skin that is warm to the touch suggests adequate circulation.
D. Bluish coloration (cyanosis) indicates poor oxygenation and compromised circulation, requiring immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While frequent repositioning helps prevent pressure ulcers, ROM exercises specifically target joint mobility rather than skin integrity.
B. ROM exercises are not primarily aimed at reducing pain, though they may help indirectly. Pain management usually involves medications and other comfort measures.
C. ROM can aid circulation to some extent, but its main benefit is maintaining joint flexibility and muscle length.
D. Contractures—permanent tightening of muscles, tendons, or joints—can be prevented through regular ROM exercises and proper positioning, making this the most appropriate answer.
Correct Answer is B
Explanation
A. Inability to touch the nose with eyes closed is part of the finger-to-nose test, not the Romberg test.
B. A positive Romberg testis indicated when the patient sways or loses balancewhile standing with feet together and eyes closed. This suggests a problem with proprioception or the vestibular system.
C. Dizziness may occur during the test but does not constitute a positive resultunless accompanied by swaying or imbalance.
D. The patient being unable to keep eyes closedis not a criterion for a positive Romberg test. The test evaluates balance, not voluntary eye closure.
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