The nurse is urgently called to the gymnasium regarding an ...

[P68T]

The nurse is urgently called to the gymnasium regarding an injured student. The student is crying in severe pain with a malformed fractured lower leg. Which proper sequence will the nurse follow to perform the initial assessment?
 
  a. Light palpation, deep palpation, and inspection
  b. Inspection, light palpation, and deep palpation
  c. Auscultation and light palpation
  d. Inspection and light palpation

Question 2

A nurse identifies lice during a child's scalp assessment. The nurse teaches the parents about hair care. Which information from the parents indicates the nurse needs to follow up?
 
  a. We will use lindane-based shampoos.
  b. We will use the sink to wash hair.
  c. We will use a fine-toothed comb.
  d. We will use a vinegar hair rinse.

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Answer to Question 1

ANS: D
Inspection is the use of vision and hearing to distinguish normal from abnormal findings. Light palpation determines areas of tenderness and skin temperature, moisture, and texture. Deep palpation is used to examine the condition of organs, such as those in the abdomen. Caution is the rule with deep palpation. Deep palpation is performed after light palpation; however, deep palpation is not performed on a fractured leg. Auscultation is used to evaluate sound and is not used to assess a fractured leg.

Answer to Question 2

ANS: A
Products containing lindane, a toxic ingredient, often cause adverse reactions; the nurse will need to follow up to correct the misconception. All the rest are correct. Instruct parents who have children with head lice to shampoo thoroughly with pediculicide (shampoo available at drugstores) in cold water at a basin or sink, comb thoroughly with a fine-toothed comb, and discard the comb. A dilute solution of vinegar and water helps loosen nits.