Nokea
How does Russell traction provide adequate skin traction?
- A. Subluxates the tibia.
- B. Does not interfere with range of motion.
- C. Prevents the knee from flexing.
- D. Supplies continuous pull in two directions.
Correct Answer: D
Rationale: Russell traction uses a sling under the knee to provide continuous pull in two directions, maintaining alignment without subluxating the tibia.
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Which observation is most likely to cause the nurse to consider the possibility of child abuse when a mother says that her young child fell down the basement stairs?
- A. Red, green, and yellow bruises on his body.
- B. Bruises are dispersed on his head, arms, and legs.
- C. A broken arm last year, and the child being described as accident-prone.
- D. The mother is very anxious for her son to get medical attention.
Correct Answer: A
Rationale: Multiple bruise colors indicate injuries at different healing stages, suggesting possible abuse rather than a single incident.
How long does it take for the toe to regain color if adequate perfusion is assessed?
- A. 3 seconds
- B. 4 seconds
- C. 5 seconds
- D. 6 seconds
Correct Answer: A
Rationale: Capillary refill in 3 seconds or less indicates adequate perfusion in a child in Bryant's traction.
What do these finding indicate?
- A. Sexual abuse
- B. Physical abuse
- C. Physical neglect
- D. Emotional abuse
Correct Answer: C
Rationale: Disheveled appearance, being unbathed, and hungry suggest physical neglect, failing to meet the child's basic needs.
What instruction would the nurse provide to an adolescent who has been fitted with a Milwaukee brace?
- A. Wear the brace directly against the skin.
- B. Wear the brace over regular clothing.
- C. Wear the brace over a T-shirt 23 hours a day.
- D. Remove the brace before sleeping.
Correct Answer: C
Rationale: Wearing the Milwaukee brace over a T-shirt for 23 hours daily protects the skin while correcting scoliosis.
What will the nurse include when caring for a child in Buck's extension?
- A. Positioning the child with hips flexed 90 degrees at all times
- B. Keeping the weights in contact with the floor
- C. Checking for skin irritation from traction equipment
- D. Releasing the weights on a schedule
Correct Answer: C
Rationale: Checking for skin irritation prevents breakdown due to friction from traction equipment in Buck's extension.