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:
Measuring the abdominal girth is a useful assessment tool in cases of suspected abdominal distension or fluid accumulation. However, in the context of intussusception, the passage of a currant jelly-like stool is a more critical indicator of the condition. While measuring abdominal girth can provide additional information, it is not the most appropriate immediate action in this scenario.
Choice B reason:
Notifying the practitioner as this is not a typical finding is incorrect because the passage of currant jelly-like stool is a classic symptom of intussusception. This stool appearance results from a mixture of mucus and blood due to the telescoping of the intestine, which compromises blood flow and causes ischemia. Therefore, this finding should be documented as expected rather than considered atypical.
Choice C reason:
Documenting the passage of currant jelly-like stool as an expected finding and planning to move forward with the procedure is the most appropriate action. This stool appearance is a hallmark sign of intussusception, indicating that the condition is present and needs to be addressed promptly. The radiologist-guided pneumoenema is a diagnostic and therapeutic procedure that can help resolve the intussusception by using air pressure to unfold the telescoped segment of the intestine. Therefore, documenting this finding and proceeding with the planned intervention is crucial.
Choice D reason:
Auscultating for bowel sounds is a standard nursing assessment technique to evaluate gastrointestinal function. However, in the context of intussusception, the passage of currant jelly-like stool is a more definitive indicator of the condition. While auscultating for bowel sounds can provide additional information about bowel activity, it is not the most appropriate immediate action in this scenario.
Correct Answer is ["A","C"]
Explanation
The correct answer is a. Vomiting, c. Tachycardia.
Choice A: Vomiting
Vomiting is a common symptom of thyroid storm. Thyroid storm is a life-threatening condition that occurs when the thyroid gland releases a large amount of thyroid hormone in a short period. This sudden surge in thyroid hormone can cause severe metabolic disturbances, leading to symptoms such as vomiting. Vomiting can result from the body’s attempt to cope with the excessive thyroid hormone levels, which can affect the gastrointestinal system.
Choice B: Constipation
Constipation is not typically associated with thyroid storm. In fact, hyperthyroidism, including thyroid storm, usually causes an increase in bowel movements or diarrhea due to the accelerated metabolism. Constipation is more commonly associated with hypothyroidism, where the thyroid gland is underactive and slows down bodily functions.
Choice C: Tachycardia
Tachycardia, or a rapid heart rate, is a hallmark symptom of thyroid storm. The excessive thyroid hormones increase the body’s metabolic rate, leading to an increased demand for oxygen and nutrients. To meet this demand, the heart rate increases significantly, often exceeding 140 beats per minute. This rapid heart rate can be dangerous and requires immediate medical attention.
Choice D: Hypotension
Hypotension, or low blood pressure, is not a typical symptom of thyroid storm. Instead, thyroid storm often causes hypertension (high blood pressure) due to the increased metabolic activity and the body’s heightened demand for oxygen and nutrients. The cardiovascular system responds by increasing blood pressure to ensure adequate blood flow to vital organs.
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