Nokea
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.
You may also like to solve these questions
What is a physiologic effect of immobilization on children?
- A. Metabolic rate increases.
- B. Venous return improves because the child is in the supine position.
- C. Circulatory stasis can lead to thrombus and embolus formation.
- D. Bone calcium increases, releasing excess calcium into the body (hypercalcemia).
Correct Answer: C
Rationale: Immobilization reduces muscle contraction, causing venous stasis, which increases the risk of thrombus and embolus formation. Metabolic rate decreases, venous return diminishes, and bone demineralization leads to hypercalcemia, not increased bone calcium.
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.
What condition can result from the bone demineralization associated with immobility?
- A. Osteoporosis
- B. Pooling of blood
- C. Urinary retention
- D. Susceptibility to infection
Correct Answer: A
Rationale: Bone demineralization from immobility leads to osteoporosis, increasing fracture and renal calculi risk. Blood pooling, urinary retention, and infection susceptibility are other immobilization effects but not directly caused by bone demineralization.
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.
Immobilization causes what effect on metabolism?
- A. Hypocalcemia
- B. Decreased metabolic rate
- C. Positive nitrogen balance
- D. Increased levels of stress hormones
Correct Answer: B
Rationale: Immobilization reduces metabolic rate, slowing systems and food intake. It causes hypercalcemia, negative nitrogen balance from muscle atrophy, and decreased stress hormone production due to reduced coping capacity.