A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing plan of care?
Assess the pulses proximal to the fracture site.
Assess the pin sites for signs of infection.
Administer pain medication at designated intervals around the clock.
Remove traction every shift and provide skin care.
The Correct Answer is A
A. Assessing the pulses proximal to the fracture site is crucial for evaluating blood circulation to the affected limb and detecting potential complications such as compartment syndrome.
B. While monitoring pin sites for signs of infection is important, the priority is ensuring adequate circulation.
C. Administering pain medication is essential for comfort but does not address potential complications from skeletal traction.
D. Removing traction every shift is not advisable as it can compromise the alignment and healing of the fracture.
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Correct Answer is A
Explanation
A. Tenderness upon palpation and generalized erythema indicate skin irritation and possible sunburn, which are signs of overexposure to PUVA treatment. This finding suggests that the client may have received excessive ultraviolet exposure, leading to skin damage.
B. Thick skin plaques topped by silvery white scales are characteristic of psoriasis vulgaris itself, not a sign of overexposure to PUVA.
C. Requiring sunglasses because sunlight hurts the eyes may indicate sensitivity but is not a specific indicator of overexposure to PUVA treatment; it could relate to other issues such as underlying eye conditions.
D. Brown, rough, greasy, wart-like papules on the face are not typically associated with PUVA overexposure but could be related to other skin conditions or lesions.
Correct Answer is D
Explanation
A. While safe sex practices can reduce the risk of STIs, they do not eliminate the risk entirely, especially in cases where partners have multiple sexual partners.
B. Not all STIs are transmitted solely through sexual intercourse; some can be transmitted through other means, making this statement overly simplistic.
C. It's important to note that asymptomatic individuals can still be carriers of STIs, so this statement may give a false sense of security.
D. Teaching the importance of adhering to the medication regimen and ensuring follow-up appointments is critical in managing gonorrhea effectively and preventing complications or reinfection. This approach emphasizes the importance of treatment compliance and ongoing health management.