A 6-year-old sustained a fractured femur and was put in Russell ...

[APUS57]

A 6-year-old sustained a fractured femur and was put in Russell traction 2 days ago. She screams in pain when she raises herself onto the bedpan. 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

Question 2

Which observation may cause the nurse to consider the possibility of child abuse when a mother says that her young child fell down the basement stairs?
 
  a. Red, green, and yellow bruises on his body
  b. Bruises are dispersed on his head, arms, and legs
  c. A broken arm last year, and the child being described as accident-prone
  d. The mother is very anxious for her son to get medical attention

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Answer to Question 1

ANS: A
Although all of these nursing diagnoses are relevant to the child in traction, pain resulting from muscle spasm and tissue trauma is the highest priority.

Answer to Question 2

ANS: A
As bruises heal, they change color in stages. Different colors of bruises indicate that injuries have not all occurred at the same time. The nurse must consider whether the bruises match the caretaker's explanation of what happened.

[APUS57]

TYSM

[Missbam101]

Excellent