Nokea
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.
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The nurse explains that Bryant's traction is reserved for children who weigh less than __ pounds.
Correct Answer: 30
Rationale: Bryant's traction is used for children weighing less than 30 pounds to ensure safe and effective application.
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.
What characteristic manifestation does the nurse caring for a child with Duchenne's muscular dystrophy document?
- A. Ambulates by holding onto furniture.
- B. Exhibits atrophy of the calf muscles.
- C. Falls frequently and is clumsy.
- D. Has delayed fine-motor development.
Correct Answer: C
Rationale: Frequent falling and clumsiness are hallmark signs of Duchenne's muscular dystrophy due to muscle weakness.
What would the nurse consider an abnormal finding on a musculoskeletal assessment of a 4-year-old child?
- A. Has inward-turned knees while standing.
- B. Walks on the toes.
- C. Appears to have flat feet.
- D. Swings his arms when walking.
Correct Answer: B
Rationale: Toe walking after age 3 may indicate a muscle problem, unlike other findings which are typical in young children.
The nurse performing a neurovascular check on a limb in traction would report and document which finding(s) as indicative of altered circulation?
- A. Pulse is equal to uncasted limb.
- B. Patient is aware of touch and warm and cold application.
- C. Limb is cool to the touch.
- D. Capillary refill is 5 seconds.
- E. Distal limb can flex and extend.
Correct Answer: C,D
Rationale: Cool limbs and capillary refill over 3 seconds indicate altered circulation, requiring immediate reporting.