Compound Fracture (Preschooler) HESI Case Study

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If a staff member is unable to reach the client's parents, what guidelines will determine the staff's ability to provide needed care?

B. Emergency care may be provided after a reasonable attempt to reach the parents has been made.

The PN and RN team leader identify that a priority nursing problem is "risk for peripheral neurovascular compromise." Which lab value would be of most concern for the nurse?

B. Hemoglobin of 9.5 g/dl (95 g/L).

The client's parents invite the nurse to attend a parenting class at her preschool to talk about car safety. A parent in the class states that her 5-year-old son is very mature for his age and feels more grown-up using an adult seatbelt. She states that he follows the rules much better when he gets to make decisions. Therefore, he is more willing to keep the seatbelt buckled. She goes on to say that he is large for his age, weighing almost 50 pounds.

B. Instruct this parent that the child's age and size still require the use of a safety seat.

Based on these assessment findings, the nurse recognizes that the client has developed compartment syndrome. In addition to notifying the HCP of this development, what action should the nurse implement?

B. Obtain equipment needed for cast removal.

Upon arrival to the unit, which nursing assessment has the greatest priority?

B. The pull of the traction on the pins.

The nurse notes that in addition to the pain, the client's foot is cool and pale. What additional focused assessment should the nurse perform? (Select all t

B. Toe movement. E. The integrity of the skin would not add any assessment data related to compartment syndrome.

Given the available medical personnel, what staff assignment is best?

D. Ongoing monitoring of the client's foot by the PN, while the UAP assists the postoperative client with crutches and the RN does the admit assessment on the new client.

After resolving the other client care needs, the nurse returns to the client's room. Which task should be delegated to the LPN at this time?

D. Spend time with the client to distract her from the discomfort.

Another parent explains to the nurse that her 6-year-old son prefers sitting in the front seat. She feels this is the safest place because her car is equipped with front and side airbags. What advice should the nurse provide to this parent?

D. The child can sit in the back seat of a car while using the manufacturer's manual lap and shoulder belts.

Which finding should the client's parents be instructed to report to the healthcare provider?

D. The client's toes are more swollen.

The client arrives on the nursing unit with her traction intact. She has a boot cast on her lower leg. Which nursing interventions should be included in the plan of care while the client is in traction? (Select all that apply. One, some, or all options may be correct.)

C. Assess toes for capillary refill and edema. E. Ensure that the amount of weight remains consistent.

The client has an open fracture. What is a priority nursing intervention?

C. Cover the wound loosely with a sterile dressing.

The nurse monitors the client's lab values. Which change in serum lab values would most likely indicate the onset of osteomyelitis?

C. Increased erythrocyte sedimentation rate (ESR).

The nurse understands that which signs and symptoms are indicative of osteomyelitis? (Select all that apply. One, some, or all options may be correct.)

A. Resistance to movement. D. Edema E. Irritability

Which nursing action has the highest priority?

c. Assess the appearance of the client's foot.

Based on this assessment, what is the best nursing intervention?

A. Administer another dose of morphine immediately.

As the nurse assumes care for the client, which actions are most important for the nurse take? (Select all that apply. One, some, or all options may be correct.)

A. Immobilize the injury. C. Assess neurovascular status every hour. E. Elevate the affected extremity.

Since the client's parents are divorced, which parent should the nurse try to contact first?

C. The parent who has been assigned legal custody by the court.

The nurse talks to the client's parents about preparing her for cast removal. Which technique is most beneficial when preparing a preschooler for a procedure that may be frightening?

D. Describe what the client will experience shortly before the procedure takes place.

How is the presence of crepitus related to this femur fracture determined?

D. Listen for a grating sound when the affected area is moved.

The ordered dose of morphine reads, "Administer morphine sulfate 0.2 mg/kg IV every 3 to 4 hours." The client weighs 33 pounds. The tubex of morphine contains 5 mg/mL. How many mL of medication should the nurse administer? (Enter numeric value only. If rounding is necessary, round to the nearest tenth.)

0.6

The UAP goes to the playroom to get the client some toys. The UAP is planning to spend some time with the client. Which activity is the best choice for the client?

A. Pretend beauty parlor.

What instructions should the nurse provide to the client and her parents about care related to the cast removal? (Select all that apply. One, some, or all options may be correct.)

A. She may feel heat or a vibration or a tickle during the removal. B. The machine to remove the cast is very noisy. D. Skin might be scaly or dry after the cast is removed.

The client reports that her pain is still controlled and she is starting to get hungry. The nurse sends the UAP to get her a snack. Which snack selection is the best choice for the client while she is immobilized?

A. Yogurt.

The client's mother tells the nurse that she doesn't know how to respond to the client when the child expresses her anger. In teaching the mother, what response should the nurse suggest she use with the client?

B. "I am sad that you are throwing things at me."

The nurse recognizes that the client is at risk for the onset of osteomyelitis. Which nursing intervention should be included in the plan of care to prevent this complication?

B. Cleanse the pin site with facility approved/doctor ordered, cleanser.

The client usually snacks on animal crackers in the morning. She has a box at her bedside. She asks the nurse if she can have some while her mother is away from the bedside. What action should the nurse take?

C. Give the client a few crackers and stay with her while she eats them.

The client insists that the play activity include Elsa, her invisible friend. While playing, the client throws some toys on the floor and scolds Elsa for dropping them. The client's mother tells her that the activity cannot continue if she is going to throw her toys. How should the nurse respond to this situation?

C. Support the mother's decision to hold the client accountable for her own misbehavior.

The client had a plaster cast applied an hour ago. The parents demonstrate lifting the cast by holding it with the palms of their hands. How should the nurse respond?

D. Acknowledge that the parents have correctly learned how to move the cast while it is wet.

What is the best response by the nurse?

D. "It is natural to be upset when your child expresses anger toward you."