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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Disposing of the child's brushes, combs, and other hair accessories can be a good practice to prevent reinfestation, but it is not the primary instruction to provide in this case.
B. Taking the child to a hair salon for a shampoo and a shorter haircut is not a necessary or recommended treatment for head lice.
C. Wash the child's bed linens and clothing in hot soapy water.
When a child has head lice, it's important to take measures to prevent the spread of lice to others and to eliminate any potential sources of reinfestation. Washing the child's bed linens and clothing in hot, soapy water is an essential step in this process to kill any lice or nits (lice eggs) that may be present on these items.
D. Rewashing the child's hair following a 24-hour isolation period is not the standard approach for treating head lice with permethrin shampoo. It is important to follow the specific instructions provided with the product and to avoid overuse or misuse of the treatment.
The primary focus should be on treating the child's hair with the appropriate lice treatment (permethrin shampoo) as directed and taking preventive measures such as washing bed linens and clothing to reduce the risk of reinfestation.
Correct Answer is A
Explanation
A. Osteosarcoma.
The presentation of localized knee pain, especially when it worsens at night, along with swelling, tenderness, and the presence of radial ossification in the soft tissues, raises concerns about the possibility of osteosarcoma. Osteosarcoma is a malignant bone tumor that commonly occurs in the long bones of the body, such as the femur, and often presents with these clinical features.
B. Rhabdomyolysis is a condition that results from the breakdown of muscle tissue and typically presents with symptoms such as muscle pain, weakness, and dark urine due to the release of muscle proteins into the bloodstream. It is not the likely cause of the findings described.
C. Growing pains are typically characterized by intermittent, mild, and diffuse musculoskeletal pain and discomfort in children and adolescents. They do not typically involve localized knee pain, swelling, or tenderness.
D. Hemosiderosis refers to the accumulation of iron in the body and is not typically associated with the described findings or symptoms.
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