Nokea
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.
You may also like to solve these questions
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 type of juvenile rheumatoid arthritis do these findings suggest?
- A. Psoriatic
- B. Enthesitis
- C. Systemic
- D. Acute febrile
Correct Answer: C
Rationale: Systemic juvenile rheumatoid arthritis presents with fever, joint swelling, warmth, tenderness, abdominal pain, and elevated inflammatory markers.
How does the pediatric skeletal system differ from that of the adult?
- A. Lower mineral content
- B. More ossification
- C. Open epiphyses
- D. Less porosity
- E. Greater strength
Correct Answer: A,C,E
Rationale: The pediatric skeletal system has lower mineral content, open epiphyses, and greater strength, with greater porosity, not less.
What type of fracture would be the most likely to alert the nurse to the possibility of physical abuse?
- A. Stress fracture
- B. Compound fracture
- C. Spiral fracture
- D. Greenstick fracture
Correct Answer: C
Rationale: Spiral fractures, caused by twisting motions, may suggest abuse if the injury history does not match the findings.
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.