HESI Case Study: Compound Fracture (Preschooler)-Madison
As the nurse assumes care for the client, which actions are most important for the nurse to take? (select all that apply)
-stabilize the injury -assess neurovascular status every hour -place an ice pack over the injury -elevate the affected extremity
Madison weighs 33lbs, and the prescribed dose is 0.2mL/kg and the vial is labeled 5mg/mL. How many mL of medication should the nurse administer?
0.6mL
Which traction is a type of skeletal traction?
90-90 Femoral
If a staff member is unable to reach Madison's parent, what guidelines will determine the staff's ability to provide needed care?
Emergency care may be provided after a reasonable attempt to reach the parents has been made. Exceptions to requiring parental consent before treating children can occur in emergency situations. Most healthcare facilities will provide emergency, life-saving medical care to a minor if unable to reach parents after a reasonable attempt has been made.
Which nursing interventions should be included in the plan of care while Madison is in traction?
-assess toes for capillary refill and edema -ensure that the amount of weight remain consistent
The nurse understand that which signs and symptoms are indicative of the osteomyelitis complication? (select all that apply)
-pain that increases with movement -edema -irritability
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? WBC of 11,500/mcL (11.5 x 109/L). Hemoglobin of 9.5 g/dl (95 g/L). Platelet count of 200 x 103/mcL (200 x 109/L). Reticulocyte count of 2% (0.02 proportion of 1.0).
Hemoglobin of 9.5 g/dl (95 g/L). This is a low value. A low hemoglobin will not provide sufficient oxygen for tissue repair.
Implementation of which nursing intervention will reduce the risk?
Initiate hourly assessment of Madison's foot distal to the fracture site.
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? Elevate the affected extremity. Obtain equipment needed for cast removal. Encourage the client to keep wiggling her toes. Place an ice pack over the affected area.
Obtain equipment needed for cast removal. Compartment syndrome is the compression of structures, such as arteries and nerves, within a closed compartment in an extremity. This complication typically occurs within 24 hours of a fracture. It should be reported to the healthcare provider (HCP) immediately because permanent damage can occur within 12 hours of identification of the syndrome. Cast removal is often necessary to relieve the pressure, and surgical fasciotomy is sometimes needed as well.
Which activity is the best choice for Madison?
Pretend beauty parlor
The client goes to surgery, where reduction and fixation is performed. Following surgery, the client is transferred to the orthopedic nursing unit where she will be in skeletal traction for several weeks.Upon arrival to the unit, which nursing assessment has the greatest priority? Inspect the pin sites for redness. The pull of the traction on the pins. The heart rate and blood pressure. The condition of the dressing.
The pull of the traction on the pins. Skeletal traction applies the pull directly on the skeletal structures. The nurse should immediately assess the pull of the traction on the pins. This is critical to the success of the traction and the first priority when the client arrives to the unit.
Which snack selection is the best choice for Madison while she is immobilized? yogurt popsicle blueberry muffin graham crackers
Yogurt. Immobilization creates a state of decreased metabolic rate. The diet should be high in protein, with small frequent feedings.
What action should the nurse take in response to how they are handling the care of the cast?
acknowledge that the parents have correctly learned how to move the cast while it is wet The palms of the hands should be used to move a wet cast to avoid finger indentations that cause pressure points.
Which nursing intervention should be included in the plan of care to prevent this complication?
cleanse around the pin site with half-strength hydrogen peroxide
How is the presence of crepitus related to this femur fracture determined?
Listen for a grating sound when the affected area is moved
Given the available medical personnel, what staff assignment is best?
ongoing monitoring of Madison's foot by the LPN, while the UAP assists the postoperative client with crutches and the nurse determines if the new client has any immediate problems
Which task should be delegated to the LPN at this time?
spend time with Madison to distract her from the discomfort
For which problem should Madison's parents be instructed to contact the healthcare provider?
warm spots are felt on the cast
What action should the nurse implement?
administer another dose of morphine immediately
In teaching the mother, what response should the nurse suggest she use with Madison?
"I am sad that you are throwing things at me." Preschoolers need limit-setting guidelines and discipline. The parent's response should focus on the activity, rather than the child. Phrasing a response beginning with "I" rather than "you" is less judging to the child.
What is the best response by the nurse?
"It is natural to be upset when your child expresses anger toward you." This open-ended statement offers the mother the opportunity to continue to express her feelings about the situation. The nurse can then offer reassurance that this expression of anger by the client is normal and help the mother find ways to deal with the situation. Therapeutic communication allows the person/patient to explore current personal issues and occcasionally painful feelings. Remaining professional means maintaining a calculated emotional distance, near enough to be involved but objective enough to be helpful.
The nurse explains to Madison and her parents that which will occur during and after the cast is removed? (select all that apply)
-she may feel heat or a vibration or a tickle during the removal -the machine to remove the cast is very noisy -skin might be scaly or dry after the cast is removed
What feature identifies Madison's fracture as an open fracture?
Bone fragments protruding through the skin.
Since Madison's parents are divorced, which parent should the nurse try to contact first?
The parent who has been assigned legal custody of Madison by the court.
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 that apply. One, some, or all options may be correct.) Select all that apply Deep tendon reflexes Toe movement. Vital signs Skin turgor.
Toe movement. Neurovascular assessment includes the "6 P's." They are pain, pallor, pulse, paresthesia, pressure, and paralysis. Changes indicate increasing pressure on the blood vessels and nerves supplying the extremity distal to the cast or injury. The integrity of the skin would not add any assessment data related to compartment syndrome. Capillary refill should be checked when compartment sydrome is suspected.
Which nursing action has the highest priority?
assess the appearance of Madison's foot
When an older child is sitting on a booster seat, where is the best place to locate the seat?
back seat of the car with lap and shoulder belts. Shoulder only automatic belts are designed to protect adults. Children should use manual shoulder belts in the rear seat. Air bags do not take the place of child safety seats or seat belts. The safest area of the car for children is the back seat. Children should use specially designed car restraints until they are 135 cm (4 ft 9 in) in height or are 8-12 years of age.
Which technique is most beneficial when preparing a preschooler for a procedure that may be frightening?
describe what the child will experience shortly before the procedure takes place
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? Tell the client that she will need to wait for her mother to return before she can have a snack. Give the client crackers to play with, but tell her not to eat any until her mother returns. Give the client a few crackers and stay with her while she eats them. Give the client a few crackers and leave her alone to enjoy her snack while watching TV.
give Madison a few crackers and stay with her while she eats them
Which change in serum lab values would most likely indicate the onset of osteomyelitis?
increased erythrocyte sedimentation rate (ESR)
How should the nurse respond?
instruct this parent that the child's age and size still require the use of a safety seat
In addition to notifying the healthcare provider of this development, what action should the nurse implement?
obtain equipment needed for cast removal
How should the nurse respond to this situation?
support the mother's decision to hold Madison accountable for her own misbehavior
