When providing care for a child who is in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement?
Cleanse pin sites as prescribed.
Monitor peripheral pulses and sensation in the right leg.
Assess skin for redness and signs of tissue breakdown.
Change position every 2 hours.
The Correct Answer is B
A. Cleansing pin sites as prescribed is important for infection prevention, but it is not the most critical intervention in the context of assessing vascular and neurologic status.
B. Monitor peripheral pulses and sensation in the right leg.
Balanced suspension skeletal traction is used to stabilize fractures or treat certain orthopedic conditions. Monitoring peripheral pulses and sensation in the right leg is a critical aspect of caring for a child in this type of traction. It is essential to ensure that the child's circulation and nerve function are not compromised. Changes in peripheral pulses and sensation can indicate potential complications, such as compromised blood flow or nerve compression, which need immediate attention to prevent further damage.
C. Assessing skin for redness and signs of tissue breakdown is important for skin care and preventing pressure ulcers, but it is secondary to monitoring peripheral pulses and sensation when the child is in traction.
D. Changing position every 2 hours is a standard nursing practice to prevent pressure ulcers and provide comfort, but it does not take precedence over monitoring circulation and sensation in the affected limb.
Peripheral pulses and sensation must be closely monitored and documented at regular intervals to ensure the child's safety and the effectiveness of the traction. Any changes in these parameters should be promptly reported to the healthcare provider.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Jaundice is a common finding in individuals with sickle cell disease due to the breakdown of sickled red blood cells. While jaundice should be monitored and reported, it is not as immediately concerning as chest pain in the context of a sickle cell crisis.
B Chest pain.
Sickle cell disease is characterized by the presence of abnormal hemoglobin that can lead to the formation of sickled red blood cells. During a sickle cell crisis, these abnormal cells can block blood vessels, leading to tissue damage and severe pain. Chest pain in a child with sickle cell disease can be indicative of a potentially life-threatening complication called acute chest syndrome, which is a serious condition that requires immediate medical attention. Acute chest syndrome can lead to impaired oxygen exchange and respiratory distress, making it a medical emergency.
C. Swelling in the hands or feet can be associated with vaso-occlusive episodes in sickle cell disease, but it may not be as immediately concerning as chest pain.
D. Ulcers on the legs can be a complication of sickle cell disease, but they are not typically as acutely life-threatening as chest pain due to acute chest syndrome.
Chest pain should be treated as a medical emergency in a child with sickle cell disease during a sickle cell crisis, and the healthcare provider should be informed immediately to initiate appropriate intervention.
Correct Answer is B
Explanation
The most important information for the nurse to provide to the mother of an 11-year-old boy with juvenile idiopathic arthritis is B.
Explanation:
A. Encouraging quiet activities such as watching television as a pain distracter can be helpful, but it should be used in conjunction with appropriate pain management strategies.
B Giving pain medication around the clock helps control the pain.
Children with juvenile idiopathic arthritis often experience chronic pain and inflammation. It's important for the mother to understand that, in some cases, simply taking pain medication when the child is in severe pain may not be the most effective approach. Pain management in chronic conditions like arthritis typically involves a more proactive and regular approach.
C. While hot baths can be soothing and offer some pain relief, they may not provide sufficient pain control for chronic conditions like juvenile idiopathic arthritis. Using hot baths can be a complementary approach but may not replace the need for pain medication.
D. Encouraging the child to rest when experiencing pain is important, but it should also be combined with appropriate pain management. Rest alone may not provide adequate pain relief for a child with arthritis.
The key information here is that giving pain medication around the clock, under the guidance of a healthcare provider, can help provide continuous pain control and improve the child's quality of life. Parents should work closely with the healthcare team to develop a comprehensive pain management plan that may include a combination of medications, physical therapy, and lifestyle modifications.
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