A 68-year-old client who had a right Total Hip Arthroplasty (THA) is returning to the orthopedic surgeon's office for a 6-week follow-up visit. While in the hospital recovering from surgery, the client experienced a pulmonary embolism (PE), which was successfully treated.
Based on the nurse's brief assessment, which findings indicate that the client is improving or progressing?
Performing activities of daily living (ADLs) without assistance.
Recent weight loss of 27 lbs.
Walking independently with the use of a cane.
Right arm is badly bruised and discolored.
Left hip is becoming more painful with movement.
No new reports of shortness of breath or chest pain.
Oxygen saturation (SpO2) of 95
Hip incision is healing with a visible hairline scar.
Correct Answer : A,C,F,G,H
Evaluating post surgical and post pulmonary embolism recovery requires assessing functional mobility, respiratory stability, and wound healing. Knowledge of normal rehabilitation milestones and the resolution of thromboembolic symptoms is necessary to determine if the client is meeting expected outcomes.
Choice A rationale
Independent performance of activities of daily living indicates restored functional capacity and successful rehabilitation after surgery. It demonstrates that the client has regained sufficient strength and coordination to manage self care tasks without exhausting their cardiovascular reserves.
Choice B rationale
Unintentional weight loss of 27 lbs within six weeks is an abnormal finding that suggests underlying pathology, malnutrition, or chronic illness. It does not indicate improvement and instead necessitates further medical investigation to rule out complications.
Choice C rationale
Transitioning to independent walking with a cane shows progress in gait stability and weight bearing tolerance on the prosthetic joint. This movement away from more restrictive assistive devices like walkers is a positive indicator of recovery.
Choice D rationale
Significant bruising and discoloration are concerning signs, potentially indicating a bleeding disorder or complications from ongoing anticoagulation therapy. This finding represents a setback or a new problem rather than a sign of successful clinical improvement.
Choice E rationale
Increased pain with movement in the surgical area suggests potential complications such as infection, prosthesis loosening, or hip dislocation. Expected progress involves a steady decrease in pain levels as the surgical site heals over the weeks.
Choice F rationale
The absence of shortness of breath and chest pain indicates that the pulmonary embolism has resolved and gas exchange is stable. This respiratory comfort suggests that pulmonary perfusion has been restored and the lungs are healing.
Choice G rationale
An oxygen saturation of 95 is within the normal range of 95 to 100 percent. This indicates adequate arterial oxygenation and demonstrates that the client no longer requires supplemental oxygen to maintain systemic tissue perfusion after recovery.
Choice H rationale
A visible hairline scar without redness, swelling, or drainage confirms successful primary intention healing of the surgical incision. This indicates that the skin integrity is restored and the risk of localized or systemic infection is decreasing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Neurological assessment using motor responses helps determine the level of brainstem involvement. This scenario requires applying knowledge of the Glasgow Coma Scale and motor pathways to distinguish between pathological posturing and more integrated, purposeful motor functions.
Choice A rationale
Purposeful movement indicates that the motor cortex or higher brain centers are successfully processing stimuli. Moving away from pain represents a significant improvement from decorticate posturing, which involves damage to the corticospinal tract and midbrain.
Choice B rationale
Decerebrate posturing involves rigid extension of the arms and legs, signifying deeper brainstem injury or herniation. This change indicates neurological deterioration rather than improvement, as it suggests the lesion has progressed lower into the pons.
Choice C rationale
Pupils that are fixed and dilated at 6 mm indicate loss of autonomic function and severe cranial nerve III compression. This is a sign of increasing intracranial pressure and brainstem failure, representing a critical clinical decline.
Choice D rationale
Flaccid paralysis is often the most severe motor finding, indicating a loss of all muscle tone and spinal reflex arcs. In the context of traumatic brain injury, this usually signals profound neurological collapse rather than recovery..
Correct Answer is B
Explanation
Evaluating neurological progression in traumatic brain injury involves applying the Glasgow Coma Scale and understanding brainstem function. Recognising the shift between abnormal posturing patterns is critical for identifying descending levels of brain injury and worsening central nervous system herniation.
Choice A rationale
Improved motor response, such as moving from abnormal posturing to localizing pain or following commands, indicates neurological recovery. This reflects better integration of the motor cortex and brainstem, suggesting that the initial injury or pressure is resolving.
Choice B rationale
Decorticate posturing involves damage to the corticospinal tract, while decerebrate posturing indicates more severe damage lower in the midbrain or brainstem. Progressing from decorticate to decerebrate signals significant neurological deterioration and potential brainstem herniation.
Choice C rationale
Decreased agitation can sometimes be a positive sign of recovery or a neutral sign of sedation. It does not specifically indicate worsening neurological status unless accompanied by a significant drop in the overall level of consciousness.
Choice D rationale
Increased responsiveness to external stimuli is a hallmark of neurological improvement. It suggests that the ascending reticular activating system and cerebral cortex are becoming more functional and integrated, which is the opposite of a worsening clinical state.
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