Nokea
The nurse stops to assist an adolescent who has experienced severe trauma when hit by a motorcycle. The emergency medical system (EMS) has been activated. The first person who provided assistance applied a tourniquet to the childs leg because of arterial bleeding. What should the nurse do related to the tourniquet?
- A. Loosen the tourniquet.
- B. Leave the tourniquet in place.
- C. Remove the tourniquet and apply direct pressure if bleeding is still present.
- D. Remove the tourniquet every 5 minutes, leaving it off for 30 seconds each time.
Correct Answer: B
Rationale: A tourniquet, used as a last resort for arterial bleeding, must remain in place until definitive treatment to avoid releasing toxins from necrotic tissue, which could cause tourniquet shock. Loosening or removing it prematurely risks systemic complications.
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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 teaching the girls varsity sports teams about the female athlete triad. What is essential information to include?
- A. They should take low to moderate calcium to avoid hypercalcemia.
- B. They have strong bones because of the athletic training.
- C. Pregnancy can occur in the absence of menstruation.
- D. A diet high in carbohydrates accommodates increased training.
Correct Answer: C
Rationale: Pregnancy is possible despite amenorrhea in the female athlete triad, necessitating contraceptive education. High calcium (1500 mg) prevents osteoporosis, low estrogen weakens bones, and high-protein, high-calorie diets, not just carbohydrates, support intense training.
A child is upset because, when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. What technique should the nurse suggest to remove this material?
- A. Soak in a bathtub.
- B. Vigorously scrub the leg.
- C. Carefully pick material off the leg.
- D. Apply powder to absorb the material.
Correct Answer: A
Rationale: Soaking in a bathtub gently removes desquamated skin and secretions over days, avoiding skin damage. Scrubbing or picking risks excoriation, and powder is ineffective; oil or lotion may help comfort, not removal.
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.
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.