Nokea
Which nursing diagnosis takes highest priority for this child?
- A. Pain resulting from tissue trauma
- B. High risk for impaired skin integrity resulting from immobility
- C. Altered growth and development related to separation from family
- D. Altered urinary elimination related to immobility and traction
Correct Answer: A
Rationale: Pain from tissue trauma and muscle spasm is the highest priority due to its immediate impact on the child's comfort.
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How long will the nurse indicate that antibiotic therapy will probably last?
- A. 2 weeks
- B. 6 weeks
- C. 2 months
- D. 3 months
Correct Answer: B
Rationale: Antibiotic therapy for osteomyelitis typically lasts 4 to 6 weeks to effectively treat the bone infection.
Which intervention would be helpful in relieving morning discomfort associated with juvenile rheumatoid arthritis?
- A. Wearing splints at night to prevent extension contractures
- B. Applying moist heat packs upon awakening
- C. Taking a warm tub bath the evening before
- D. Sleeping with two pillows under the head
Correct Answer: B
Rationale: Moist heat packs upon awakening reduce morning stiffness associated with juvenile rheumatoid arthritis.
What do these finding indicate?
- A. Sexual abuse
- B. Physical abuse
- C. Physical neglect
- D. Emotional abuse
Correct Answer: C
Rationale: Disheveled appearance, being unbathed, and hungry suggest physical neglect, failing to meet the child's basic needs.
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.
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.