Which of the following are important to assess when a child has a cast? (Select all that apply)
Skin turgor underneath cast
Skin temperature
Pulses
Pain
Correct Answer : B,C,D
Choice A reason:
Assessing skin turgor underneath the cast is not feasible because the cast covers the skin, making it difficult to evaluate turgor directly. Skin turgor is typically assessed to determine hydration status, but it is not a primary concern when monitoring a child with a cast. The focus should be on assessing for signs of complications such as swelling, circulation issues, and pain.
Choice B reason:
Skin temperature is an important assessment when a child has a cast. Changes in skin temperature, such as increased warmth, can indicate infection or inflammation, while a cooler temperature may suggest compromised circulation. Regularly checking the skin temperature around the cast can help identify potential complications early.
Choice C reason:
Assessing pulses is crucial when a child has a cast. Checking the pulses distal to the cast (e.g., in the fingers or toes) helps ensure that there is adequate blood flow to the extremity. Diminished or absent pulses can indicate compromised circulation, which requires immediate medical attention to prevent tissue damage.
Choice D reason:
Pain assessment is essential for a child with a cast. Pain can be an indicator of complications such as pressure sores, infection, or compartment syndrome. Monitoring the child’s pain levels and addressing any complaints of pain promptly is important for their comfort and to prevent further issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Performing an ultrasound to determine if there is urinary retention is not the immediate priority action. While an ultrasound can help assess urinary retention, the presence of edema, redness, and the foreskin being behind the glans penis suggests a condition known as paraphimosis. Paraphimosis is a medical emergency that requires prompt attention to prevent complications such as tissue damage. Therefore, alerting the ER physician is the priority action.
Choice B reason:
Asking the parents specifically how long the infant has not voided is important for gathering information, but it is not the immediate priority action. The clinical signs of edema, redness, and the foreskin being behind the glans penis indicate a potential emergency that requires immediate medical intervention. While obtaining a detailed history is important, the nurse should first alert the ER physician to ensure timely management.
Choice C reason:
Alerting the ER physician to the patient’s condition is the correct priority action. The presence of edema, redness, and the foreskin being behind the glans penis suggests paraphimosis, which is a urological emergency. Prompt intervention is necessary to reduce the foreskin and restore normal blood flow to prevent tissue damage3. The ER physician can provide the necessary treatment and management for this condition.
Choice D reason:
Continuing to monitor the patient in the ER setting is not appropriate without first addressing the potential emergency. The signs of edema, redness, and the foreskin being behind the glans penis indicate a condition that requires immediate medical attention. Monitoring alone is insufficient; the nurse must alert the ER physician to ensure prompt intervention.
Correct Answer is A
Explanation
The correct answer is a) Androgens.
Choice A reason:
Congenital adrenal hyperplasia (CAH) is a group of genetic disorders affecting the adrenal glands, which are responsible for producing vital hormones such as cortisol, aldosterone, and androgens. In CAH, there is a deficiency of the enzyme 21-hydroxylase, which is crucial for the synthesis of cortisol and aldosterone. As a result, the adrenal glands overproduce androgens, leading to symptoms such as ambiguous genitalia in newborns, early puberty, and rapid growth. Androgens are male sex hormones, including testosterone, which play a significant role in the development of male characteristics.
Choice B reason:
Vitamin K is a fat-soluble vitamin essential for blood clotting and bone health. It is not related to the overproduction of hormones in congenital adrenal hyperplasia. Vitamin K deficiency can lead to bleeding disorders, but it does not cause the symptoms associated with CAH, such as ambiguous genitalia or early puberty. Therefore, this choice is incorrect.
Choice C reason:
Gonadotropins are hormones produced by the pituitary gland that stimulate the gonads (ovaries and testes) to produce sex hormones and gametes (eggs and sperm). While gonadotropins play a role in sexual development and reproduction, they are not overproduced in congenital adrenal hyperplasia. The primary issue in CAH is the overproduction of androgens due to enzyme deficiencies in the adrenal glands. Therefore, this choice is incorrect.
Choice D reason:
Vitamin D is a fat-soluble vitamin essential for calcium absorption and bone health. It is not related to the overproduction of hormones in congenital adrenal hyperplasia. Vitamin D deficiency can lead to bone disorders such as rickets in children and osteomalacia in adults, but it does not cause the symptoms associated with CAH. Therefore, this choice is incorrect.
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