A nurse is caring for a school-age child who has a fracture to the right femur.
Which of the following findings is the nurse's priority?
Capillary refill less than 2 seconds.
Tingling in the right foot.
Respiratory rate 24/min.
2+ right pedal pulse.
The Correct Answer is B
Choice A rationale
Capillary refill less than 2 seconds is a normal finding and suggests adequate perfusion. It is not indicative of a priority concern in this context.
Choice B rationale
Tingling in the right foot can indicate nerve damage or compromised circulation, which is critical to address in a patient with a fracture. This symptom could suggest complications like compartment syndrome, requiring immediate medical attention.
Choice C rationale
Respiratory rate of 24/min is slightly elevated but not directly related to the fracture's immediate complications. It requires monitoring but is not the priority.
Choice D rationale
A 2+ right pedal pulse indicates a normal pulse and adequate circulation in the foot. While important, it does not represent an immediate concern in this context.
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Correct Answer is ["B","C"]
Explanation
Choice A rationale
Methotrexate is an immunosuppressant and chemotherapeutic agent, not typically used for treating muscle spasms in cerebral palsy. It is primarily used for autoimmune conditions and certain cancers.
Choice B rationale
Baclofen is a muscle relaxant and antispasmodic agent commonly used to treat muscle spasms in patients with cerebral palsy. It works by acting on the central nervous system to reduce spasticity and improve motor function.
Choice C rationale
Diazepam is a benzodiazepine that can also be used to manage muscle spasms. It has a calming effect on the brain and nerves, helping to reduce muscle stiffness and spasms in patients with cerebral palsy.
Choice D rationale
Prednisone is a corticosteroid that is used for its anti-inflammatory properties. While it may be used in various inflammatory conditions, it is not typically prescribed for muscle spasms in cerebral palsy.
Correct Answer is A
Explanation
Choice A rationale
Ensuring the client's weights are hanging freely from the bed is crucial in maintaining the proper amount of traction force. This prevents complications and ensures that the traction is effective in reducing the fracture and alleviating pain.
Choice B rationale
Checking the client's bony prominences every 12 hours is important for preventing pressure ulcers and skin breakdown. However, the timing might need to be more frequent depending on the client's overall health and risk factors.
Choice C rationale
Cleansing the client's pin sites with povidone-iodine is a common practice to prevent infection. However, current guidelines often recommend alternative cleaning solutions, such as chlorhexidine, due to better evidence of efficacy.
Choice D rationale
Loosening the knots on the ropes if the client is experiencing pain can compromise the effectiveness of the traction. Adjustments should be made by a healthcare professional to ensure the correct amount of force is applied without causing additional harm.