Nokea
The nurse is teaching parents the proper use of a hip-knee-ankle-foot orthosis (HKAFO) for their 4-year-old child. The parents demonstrate basic essential knowledge by making what statement?
- A. Alcohol will be used twice a day to clean the skin around the brace.
- B. Weekly visits to the orthotist are scheduled to check screws for tightness.
- C. Initially, a burning sensation is expected and the brace should remain in place.
- D. Condition of the skin in contact with the brace should be checked every 4 hours.
Correct Answer: D
Rationale: Checking skin every 4 hours prevents breakdown from HKAFO contact points. Alcohol dries skin, parents can check screws, and burning requires brace removal and orthotist consultation, not tolerance.
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A student athlete was injured during a basketball game. The nurse observes significant swelling. The player states he thought he heard a pop, that the pain is pretty bad, and that the ankle feels as if it is coming apart. Based on this description, the nurse suspects what injury?
- A. Sprain
- B. Fracture
- C. Dislocation
- D. Stress fracture
Correct Answer: A
Rationale: A sprain, common in ankle injuries, involves ligament stretching or tearing, often with a pop sound, severe pain, and joint instability. Fractures involve bone, dislocations disrupt joint alignment, and stress fractures result from repetitive stress, not acute trauma with a pop.
A 7-year-old child has just had a cast applied for a fractured arm with the wrist and elbow immobilized. What information should be included in the home care instructions?
- A. No restrictions of activity are indicated.
- B. Elevate casted arm when both upright and resting.
- C. The shoulder should be kept as immobile as possible to avoid pain.
- D. Swelling of the fingers is to be expected. Notify a health professional if it persists more than 48 hours.
Correct Answer: B
Rationale: Elevating the casted arm during rest and in a sling when upright promotes venous return and reduces swelling. Strenuous activity is limited initially, shoulder movement is encouraged, and finger swelling requires immediate reporting to prevent neurovascular damage.
Parents bring a 7-year-old child to the clinic for evaluation of an injured wrist after a bicycle accident. The parents and child are upset, and the child will not allow an examination of the injured arm. What priority nursing intervention should occur at this time?
- A. Send the child to radiology so radiography can be performed.
- B. Initiate an intravenous line and administer morphine for the pain.
- C. Calmly ask the child to point to where the pain is worst and to wiggle fingers.
- D. Have the parents hold the child so that the nurse can examine the arm thoroughly.
Correct Answer: C
Rationale: Gaining the child?s trust by calmly assessing pain location and finger movement is the priority to evaluate neurovascular status without increasing distress. Radiography requires initial assessment, morphine is premature, and restraining the child escalates anxiety.
The nurse uses the five Ps to assess ischemia in a child with a fracture. What finding is considered a late and ominous sign?
- A. Petaling
- B. Posturing
- C. Paresthesia
- D. Positioning
Correct Answer: C
Rationale: Paresthesia, indicating nerve compression or ischemia distal to the fracture, is a late and ominous sign requiring immediate action to prevent permanent damage within 6-8 hours. Petaling is cast maintenance, posturing isn?t ischemia-related, and positioning affects comfort, not ischemia.
The nurse is caring for a hospitalized adolescent whose femur was fractured 18 hours ago. The adolescent suddenly develops chest pain and dyspnea. The nurse should suspect what complication?
- A. Sepsis
- B. Osteomyelitis
- C. Pulmonary embolism
- D. Acute respiratory tract infection
Correct Answer: C
Rationale: Pulmonary embolism, often from fat emboli in long bone fractures, is likely within 12-24 hours post-injury, presenting with chest pain and dyspnea. Sepsis and osteomyelitis involve fever, and respiratory infections typically cause nasal congestion, not acute chest pain.