HESI RN FUNDAMENTALS
The nurse is caring for a 14-year-old boy in Buck traction for a slipped capital femoral epiphysis (SCFE).
Which of the following would the nurse include when completing a neurovascular assessment of the
affected leg? Select all that apply.
a) Sensation
b) Capillary refill...
hesi rn fundamentals the nurse is caring for a 14 year old boy in buck traction for a slipped capital femoral epiphysis scfe which of the following would the nurse include when completing a neurova
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HESI RN FUNDAMENTALS
The nurse is caring for a 14-year-old boy in Buck traction for a slipped capital femoral epiphysis (SCFE).
Which of the following would the nurse include when completing a neurovascular assessment of the
affected leg? Select all that apply.
a) Sensation
b) Capillary refill
c) Color
d) Vital signs
e) Pulse
c)Color
a)Sensation
e)Pulse
b)Capillary refill
Explanation:
A neurovascular assessment includes assessing for color, movement, sensation, edema, and quality of
pulses. Vital signs are not a component of a neurovascular assessment.
The nurse is discussing types of treatment used when working with children who have orthopedic
disorders. Which of the following forms of treatment covers the lower part of the body, usually from the
waist down, and either one or both legs while leaving the feet open?
a) Internal fixation device
b) Stockinette
c) Spica cast
d) External fixation device
c)Spica cast
Explanation:
The hip spica cast covers the lower part of the body, usually from the waist down, and either one or both
legs while leaving the feet open. The cast maintains the legs in a frog-like position. Usually, there is a bar
placed between the legs to help support the cast.
In caring for a child in traction, of the following interventions, which is the highest priority for the nurse?
a) The nurse should clean the pin sites at least once every eight hours.
b) The nurse should monitor for decreased circulation every four hours.
c) The nurse should record accurate intake and output.
d) The nurse should provide age-appropriate activities for the child.
b)The nurse should monitor for decreased circulation every four hours.
Explanation:
Any child in traction must be carefully monitored to detect any signs of decreased circulation or
neurovascular complications. Cleaning pin sites is appropriate for a child in skeletal traction. Providing
age-appropriate activities and monitoring intake and output are important interventions for any ill child
but would not be the highest priority interventions for the child in traction.
,The nurse is doing neurovascular checks on a child who has had a cast applied to treat a fracture. The
nurse observes for diminished or absent sensation and numbness or tingling. In doing this the nurse is
monitoring for which of the following symptoms?
a) Pallor
b) Pain
c) Paralysis
d) Paresthesia
d)Paresthesia
Explanation:
Paresthesia is diminished or absent sensation or numbness or tingling. Pallor is paleness of color and
paralysis is the loss of function.
The nurse is assessing a 10-year-old girl recently fitted with a cast on her wrist. Which assessment finding
would alert the nurse to a possible infection?
a) Diminished pulse
b) Delayed capillary refill
c) Pallor of the fingers
d) Drainage on the cast
d)Drainage on the cast
Explanation:
Drainage on the cast could indicate an infection. Pale fingers would suggest impaired circulation. Delayed
capillary refill would suggest impaired circulation. Diminished pulse would suggest impaired circulation.
The type of fracture often seen in young children is a fracture in which there is not complete ossification
of the bone and the bone bends and just partially breaks. This type of fracture is which of the following?
a) Epiphyseal
b) Spiral
c) Complete
d) Greenstick
d)Greenstick
Explanation:
Greenstick fractures are one kind of incomplete fracture, caused by incomplete ossification, common in
children. The bone bends and often just partially breaks.
The nurse is working with a group of caregivers of school-age children discussing fractures. The nurse
explains that if the fragments of fractured bone are separated, the fracture is said to be which of the
following?
a) Incomplete
b) Complete
, c) Spiral
d) Greenstick
b)Complete
Explanation:
If the fragments of fractured bone are separated, the fracture is said to be complete. If fragments remain
partially joined, the fracture is termed incomplete. Green stick fractures are one kind of incomplete
fracture, caused by incomplete ossification, common in children. Spiral fractures twist around the bone.
You assist with the application of a full-body plaster cast to a child. The child immediately becomes
diaphoretic and complains of being hot. Which nursing intervention would be indicated?
a) Advise the child that this is to be expected.
b) Observe the child for infection.
c) Suggest removal of the cast to the orthopedist.
d) Moisten the cast with cool water.
a)Advise the child that this is to be expected.
Explanation:
Plaster becomes hot as it sets. This effect is reduced with newer plastic casts. This is a normal
expectation about which to educate the child before the application of the cast. If discomfort continues,
notify the provider. Infection would not present in this way with a cast application. Never moisten a case.
An infant appears floppy, sucks poorly, and has weak respiratory effort. She is diagnosed with congenital
myasthenia gravis. In explaining this condition to the infant's mother, which of the following should she
mention as the cause of the condition?
a) An inherited disorder involving faulty neurotransmitter transmission or reception
b) Infection of the bone by Streptococcus pyogenes
c) Degeneration of skeletal muscle fibers, possibly due to viral infection
d) An autoimmune disorder involving the development of circulating antibodies against body cells
a)An inherited disorder involving faulty neurotransmitter transmission or reception
Explanation:
With myasthenia gravis, there is interference in ACh processing, which leads to symptoms of progressive
muscle weakness or inability to contract. Congenital myasthenia appears to be an inherited disorder that
results in faulty ACh transmission or reception. Dermatomyositis occurs from degeneration of skeletal
muscle fibers. The cause of the disorder is unknown, although either a viral infection or an autoimmune
basis is suspected. The cause of juvenile arthritis is unknown, although it is thought to be an
autoimmune process in which a child develops circulating antibodies (immunoglobulins) against body
cells. Osteomyelitis is infection of the bone by Streptococcus pyogenes.
The nurse caring for a patient in a body cast knows that immobility can cause contractures, loss of
muscle tone, or fixation of joints. Which of the following nursing interdisciplinary interventions are
recommended to help prevent these adverse conditions?
a) Encourage child to stifle cough and take shallow breaths to prevent ineffective breathing patterns.
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