NU272 Week 2 HESI Case Study: Compound Fracture (Preschooler)

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? "You shouldn't act out by throwing things at me." "I am sad that you are throwing things at me." "I will not stay here if you keep throwing things." "Throwing things is not the way good girls behave."

"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.

Therapeutic Communication: Displaced Anger: Several days later, the client throws her toys at her mother. Her mother is in tears and asks the nurse, "Why does she only get angry with me? She never yells at the nurses or her father." What is the best response by the nurse? "You are the one providing all the discipline. It is natural for her to be angry at you." "Do you believe she would be happier being with her father rather than with you?" "You should not allow her to become that angry because it is harmful for both of you." "It is natural to be upset when your child expresses anger toward you."

"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 prescribed 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

Discharge Teaching: Cast Care: After 3 weeks the traction is discontinued, a long leg cast is applied, and the client is scheduled for discharge from the hospital. 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 repond? Ask the parents if they feel too overwhelmed to learn cast care at the present time. Demonstrate the correct technique for moving the cast using only the fingertips. Insrutct the parents to use only one hand to lift the cast. Acknowledge that the parents have correctly learned how to move the cast while it is wet.

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.

The nurse monitors the client's lab values. Which change in serum lab values would most likely indicate the onset of osteomyelitis? Decreased hemoglobin (Hgb). Decreased white blood cells (WBC). Increased erythrocyte sedimentation rate (ESR). Increased creatine phosphokinase (CPK).

Increased erythrocyte sedimentation rate (ESR). The ESR will increase during an inflammatory process, which would be present in acute osteomyelitis, an infection of the bone.

The nurse assesses for pain. The child points to the FACES pain scale rating indicating a high level of pain, but she is lying still and seems vague about the location of the pain when asked by the nurse. A prescription for IV morphine every 4 hours is available. The child is due a dose of morphine, and the transport team is en route to escort her to surgery. Based on this assessment, what is the best nursing intervention? Administer another dose of morphine immediately. Ask the OR nurse to administer the medication once the child arrives to the OR. Use distraction methods rather than analgesics until she goes to surgery. Hold the dose due and document that pain assessment findings are inconsistent.

Administer another dose of morphine immediately. Lack of activity may indicate pain in the preschooler, an age at which a child is normally always on the go. Preschoolers may not be able to localize pain clearly. The child has clearly identified the degree of pain on the FACES scale and should be medicated accordingly.

A Complication Occurs: The child has been resting comfortably since surgery. She is receiving morphine 3 mg IV every 4 hours, and she has consistently indicated adequate pain control via the FACES pain scale and through remarks to her mother, who has been staying at her bedside. Twenty hours after surgery, the nurse administers the next scheduled dose of morphine. Two hours later, the child is crying and agitated. She points to her foot and cries, "There, there, it hurts there." Which nursing action has the highest priority? Administer a breakthrough dose of morphine. Redirect the client's attention to a new toy. Assess the appearance of the client's foot. Monitor the child's vital signs and oxygen saturation.

Assess the appearance of the client's foot. Pain distal to the site may be the first sign of a serious complication needing immediate attention.

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.). Select all that apply: Remove the traction for 10 minutes every hour. Keep weights securely positioned on the floor. Assess toes for capillary refill and edema. Attach the ropes to the footboard to prevent sliding. Ensure that the amount of weight remains consistent.

Assess toes for capillary refill and edema. Decreased perfusion to the foot or increased edema could lead to a potentially life-threatening complication. Ensure that the amount of weight remains consistent. The nurse should assess the amount of the weight regularly to ensure that no changes have been made to the prescribed amount of traction. Well-meaning family and friends or older children may remove weights.

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? Petal the edges of the boot cast with adhesive tape. Cleanse the pin site with half-strength hydrogen peroxide. Increase the intake of vitamin C in the client's diet. Apply an elastic stocking to the unaffected leg.

Cleanse the pin site with half-strength hydrogen peroxide. Persons with skeletal traction are at high risk for osteomyelitis because of the potential for direct entry of microorganisms at the pin site. Cleansing the pin site with half-strength hydrogen peroxide may be initiated to reduce this risk.

The child has an open fracture. What is a priority nursing intervention? Administer oral pain medication hourly. Apply heat to the affected area. Cover the wound loosely with a sterile dressing. Discuss the post op ambulation schedule with the child.

Cover the wound loosely with a sterile dressing. The area is covered with a sterile dressing to prevent contamination of organisms from the skin.

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? Call the child life therapy team to explain the procedure. Remind the child that removing the cast means she can return to normal activities. Reassure the child that there is nothing scary about the procedure. Describe what the child will experience shortly before the procedure takes place.

Describe what the child will experience shortly before the procedure takes place. Preparation for the procedure helps reduce anxiety.

A four-year-old is brought to the emergency department (ED) by ambulance following an automobile accident that occurred while the child was headed to the park with her sister, who is also her babysitter. The child sustained a compound fracture of the femur, which requires surgical reduction, followed by skeletal traction. Ethical-Legal Issues: Consent for Care: The child's teenage sister accompanies her to the hospital. She reports that their parents are both at work. If a staff member is unable to reach the child's parents, what guidelines will determine the staff's ability to provide needed care? A minor child can give permission and consent for care and is then considered emancipated. Emergency care may be provided after a reasonable attempt to reach the parents has been made. Since the sister has responsibility for the child, she can give informed consent for needed procedures. A minor child can assent to care, which is considered equivalent to an adult giving informed consent for care.

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

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 the client a few crackers and stay with her while she eats them. It is important to maintain the client's routine. Therefore, she should be allowed to have her usual morning snack. It is also important to supervise the client because preschoolers have great imaginations and she may choose to hide some of the animal crackers in her cast if left alone while having her snack.

The nurse identifies that a priority nursing diagnosis is injury 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.

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.). Select all that apply: Immobilize the injury. Perform range of motion (ROM) exercises to the affected limb. Assess neurovascular status every hour. Realign the bone to reduce pain. Elevate the affected extremity.

Immobilize the injury. This will prevent further damage to the leg. Assess neurovascular status every hour. This helps the nurse to verify adequate profusion to the extremity. Elevate the affected extremity. Emergency care of a fracture includes assessment, determination of mechanism of injury, covering the wound, immobilization, monitoring of neurovascular status, elevation, application of cold therapy, and application of traction if needed. Elevation will decrease swelling to the injury.

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.How should the nurse respond? Reassure this parent that the child is large enough to safely use an adult seatbelt. Instruct this parent that the child's age and size still require the use of a safety seat. Support this parent's desire to increase the child's independent decision-making. Redirect the topic to types of injuries that occur when car seats are not used correctly.

Instruct this parent that the child's age and size still require the use of a safety seat. The American Academy of Pediatric and National Highway Traffic Safety Administration now recommend that children up to age 2 ride in a rear- facing safety seat until the child has outgrown the manufacturer's height and weight recommednations; then transition the child to a forward- facing safety seat with a harness in the back seat of the vehicle. The belt-positioning booster seats are tall and weigh 15.9 to 36.3 (35-80 lbs), and are used for children who are less than 145 cm (4 ft 9 in) depending on the type of booster seat.

Clinical Manifestations: The child's parents are reached and they are both on their way to the hospital. They both give telephone consent for her emergency care. The nurse performs an assessment of the affected leg and notes leg deformity, swelling, and ecchymosis. EMS documentation indicates the presence of crepitus. How is the presence of crepitus related to this femur fracture determined? Observe the area around the fracture for swelling, pain, and tenderness. Observe the area distal to the fracture for spasms or rigidity. Gently palpate over or around the wound and listen for a crackling sound. Listen for a grating sound when the affected area is moved.

Listen for a grating sound when the affected area is moved. Creptius is a grating sound that occurs at the fracture site.

Based on these assessment findings, the nurse recognizes that the child has developed compartment syndrome. In addition to notifying the healthcare provider 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 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.

Management Considerations: Delegation: The nurse administers an additional dose of analgesic to the client after conferring with the healthcare provider and the client reports that her pain is tolerable. Other clients require assistance, so the nurse needs to utilize her team members to effectively care for all clients. A client with a pelvic fracture is being transferred from the ED and a postoperative client with crutches needs assistance ambulating to the bathroom. A licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) are available to work with the nurse. Given the available medical personnel, what staff assignment is best? Ongoing monitoring of the client's foot by the LPN, while the nurse assists the postoperative client with crutches and the UAP determines if the new client has any immediate problems. Ongoing monitoring of the client's foot by the nurse, while the UAP assists the postoperative client with crutches and the LPN determines if the new client has any immediate problems. Ongoing monitoring of the client's foot by the UAP, while the nurse assists the postoperative client with crutches and the LPN determines if the new client has any immediate problems. Ongoing monitoring of the client'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.

Ongoing monitoring of the client'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. Ongoing monitoring of the client's foot can be performed by the LPN since the nurse has already made an assessment and taken action. The UAP can assist the client with crutches, which allows the nurse to assess the problems of a new client. The nurse is the only member of the team who has the expertise to perform an admission assessment and determine client needs and problems.

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? Pretend beauty parlor. Monopoly board game. Fifty-piece puzzle. Looking at picture books.

Pretend beauty parlor. Preschoolers enjoy imitative and dramatic play, and they especially enjoy adult make believe. This activity will help the client with fine motor skills, as well as communication skills, and should keep her engaged for a period of time. Preschoolers also enjoy things like village and farm sets, hand puppets, simple handicrafts, and letter flash cards.

The nurse understands that which signs and symptoms are indicative of osteomyelitis? (Select all that apply. One, some, or all options may be correct.). Select all that apply: Resistance to movement. Bradycardia. Hypothermia. Edema. Irritability.

Resistance to movement. The client's pain will be constant but will increase with movement. Edema. The client will have noticeable edema. Irritability. The client will be uncomfortable and irritable.

Health Promotion: Use of Infant/Child Car Seats: When the client returns for cast removal, the nurse uses a doll that allows the client to role-play the procedure of cast removal. The nurse tells the client that the cast-cutter makes a noise, but if it touches her leg, it will probably feel like a "tickle." 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.). 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. Lotions should not be applied on the legs for 1 week after cast removal. Skin might be scaly or dry after the cast is removed. The client will be ready to walk on her foot without issue once the cast is removed.

She may feel heat or a vibration or a tickle during the removal. The client should be spoken to with words she may understand, and the removal does get worse and vibrate. The machine to remove the cast is very noisy. It is appropriate to warn the client that the machine is loud. Skin might be scaly or dry after the cast is removed. The skin is most likely going to be dry from cast placement.

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? Revise the plan of care to reflect the recent complication. Teach the client's parents about compartment syndrome. Evaluate the effectiveness of the dose of morphine administered. Spend time with the client to distract her from the discomfort.

Spend time with the client to distract her from the discomfort. This is an appropriate nursing responsibility for the LPN.

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? Remind the mother that the client's actions are normal and to be expected. Help the mother develop a plan to reduce the client's need for an imaginary friend. Support the mother's decision to hold the client accountable for her own misbehavior. Advise the mother that imaginary playmates at this age indicate regressive behavior.

Support the mother's decision to hold the client accountable for her own misbehavior. Parents can acknowledge the presence of imaginary friends/playmates, but should not allow the child the use the playmate/friend to avoid punishment or responsibility.

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? The chilld can sit in a booster seat in the front passenger seat of a car with airbags. The child can sit in the front passenger seat of a car without airbags, using the manufacturer's shoulder belt. The child can sit in the back seat of a car without a booster seat, but only if using the manufacturer's lap belt. The child can sit in the back seat of a car while using the manufacturer's manual lap and shoulder belts.

The child can sit in the back seat of a car while using the manufacturer's manual 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 finding should The client's parents be instructed to report to the healthcare provider? The cast sounds hollow when tapped. The client's capillary refill is less than 2 seconds. The client reports itching inside the cast. The client's toes are more swollen.

The client's toes are more swollen. Swelling could be a sign of impaired circulation.

Since the child's parents are divorced, which parent should the nurse try to contact first? The parent from whose house the sister assumed care of the child (physical custody). The parent in whose home the child lives the majority of the time (physical custody). The parent who has been assigned legal custody by the court. Both parents must be contacted, even if they do not share joint legal custody of the child.

The parent who has been assigned legal custody by the court. The parent who has been assigned legal custody has the right to give consent.

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.

The nurse notes that in addition to the pain, the child's foot is cool and pale. What additional 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. The integrity of the skin would not add any assessment data related to compartment syndrome.

Toe movement. Neurovascular assessment includes the "5 Ps." They are pain, pallor, pulse, paresthesia, 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.

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