What is an appropriate nursing intervention when caring for a ...

[lbcchick]

What is an appropriate nursing intervention when caring for a child in traction?
 
  a. Removing adhesive traction straps daily to prevent skin breakdown
  b. Assessing for tightness, weakness, or contractures in uninvolved joints and muscles
  c. Providing active range of motion exercises to affected extremity three times a day
  d. Keeping child prone to maintain good alignment

Question 2

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

[Laurenleakan]

Answer to Question 1

ANS: B
Traction places stress on the affected bone, joint, and muscles. The nurse must assess for tightness, weakness, or contractures developing in the uninvolved joints and muscles. The adhesive straps should be released or replaced only when absolutely necessary. Active, passive, or active with resistance exercises should be carried out for the unaffected extremity only. Movement is expected with children. Each time the child moves, the nurse should check to ensure that proper alignment is maintained.

Answer to Question 2

ANS: C
Paresthesia distal to the injury or cast is an ominous sign that requires immediate notification of the practitioner. Permanent muscle and tissue damage can occur within 6 hours. The other signs of ischemia that need to be reported are pain, pallor, pulselessness, and paralysis. Petaling is a method of placing protective or smooth edges on a cast. Posturing is not a sign of peripheral ischemia. Finding a position of comfort can be difficult with a fracture. It would not be an ominous sign unless pain was increasing or uncontrollable.