Musc/Neuro

The nurse identifies that a priority nursing diagnosis for a child with a newly broken femur is "Injury risk for peripheral neurovascular compromise." Implementation of which nursing intervention will reduce this risk?

• Perform hourly assessments of the child's level of consciousness. 

• Initiate hourly assessment of the child's foot distal to the fracture site

• Assign an unlicensed assistive personal to measure the child’s vitals hourly

• Evaluate the child for orthostatic hypertension 

An 8-year-old child sustained a fracture in the epiphyseal plate of her right femur when she fell out of a tree and landed on the edge of a picnic table. The nurse caring for her should consider which of the following?

• Bone growth can be affected with this type of fracture.

• This is an unusual fracture in young children.

• This type of fracture is inconsistent with a fall as reported

• Healing is usually delayed in this type of fracture

An infant is diagnosed with bacterial meningitis. Which of the following is a priority nursing intervention?

• Administering oral antibiotics

• Keeping the infant in a supine position

• Encouraging the infant to drink fluids

• Isolating the infant from other infants

A 3-year-old child is brought to the emergency department with a febrile seizure. Which of the following is the priority nursing intervention?

• Administer antipyretics as ordered

• Check the child's airway and breathing

• Administer an antiepileptic medication

• initiate seizure precautions.

Which clinical manifestation of increasing intracranial pressure (ICP) will the nurse expect to assess in the 3-year-old diagnosed with meningitis?

• Seizures

• Hyperactivity

• Bulging fontanels

• Decreased respiratory rate

• Difficulty with speech

Which of the following manifestations would lead the nurse to suspect developmental dysplasia of the hip? Select all that apply

• Uneven gluteal folds

• Positive Kernig sign

• Clicking when leg is rotated out

• Positive Ortolani sign

• Stepping reflex