A client is brought to the emergency department by ambulance after stepping in a hole and falling. During the assessment, the nurse notes that the right leg is shorter than the left leg the right hip is noticeably deformed and acute pain is noted. Imaging does not reveal a fracture. What is the most likely explanation for this client's signs and symptoms?

Right hip dislocation

Right hip contusion

Right hip strain

Right hip osteoarthritis

Answer and Explanation

The Correct Answer is A

A. Right hip dislocation: In a hip dislocation, the head of the femur is forced out of the acetabulum, which is the socket in the pelvis. This can cause a noticeably shorter leg, hip deformity, and acute pain. Imaging might not show a fracture in the case of a dislocation.

B. Right hip contusion: A hip contusion is a bruise on the hip, usually caused by a direct blow or trauma. While it can cause pain and swelling, it typically does not result in a noticeably shorter leg or hip deformity.

C. Right hip strain: Hip strain refers to damage to the muscles or tendons around the hip joint due to overuse or sudden twisting movements. While it can cause pain, it does not typically lead to a noticeable leg shortening or hip deformity.

D. Right hip osteoarthritis: Osteoarthritis is a degenerative joint disease that can affect the hip joint. It leads to joint pain and stiffness but does not usually cause a noticeable leg shortening or acute deformity unless there are severe complications, which are not mentioned in the scenario.

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Correct Answer is B

Explanation

A. Morse Scale:

The Morse Scale, also known as the Morse Fall Scale, is used to assess a patient's risk of falling. It evaluates various factors such as history of falling, secondary diagnosis, ambulatory aids, IV therapy, gait, and mental status. It is primarily focused on assessing the risk of falls, not pressure ulcers.
B. Braden Scale:

As previously mentioned, the Braden Scale assesses a patient's risk for developing pressure ulcers. It takes into account sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The scale helps healthcare providers determine the level of risk a patient has for developing pressure sores and guides interventions to prevent them.

C. Bristol Scale:

The Bristol Stool Scale is used to classify the form of human feces into seven categories. It is a medical aid designed to classify the form of human feces into seven categories. This scale is primarily used to assess bowel movements and is unrelated to pressure ulcers.
D. Hendrich II Scale:

The Hendrich II Fall Risk Model is a tool designed to identify patients at risk for falls. It includes factors such as confusion, symptomatic depression, altered elimination, dizziness, male gender, and the use of antiepileptics, benzodiazepines, or non-opioid analgesics. Similar to the Morse Scale, it focuses on assessing the risk of falls, not pressure ulcers.

A. Chronic pain B. Impaired skin integrity C. Risk for injury D. Ineffective tissue perfusion

Correct Answer is D

Explanation

A. Chronic pain - Chronic pain is a concern for the client, but addressing the underlying issue of ineffective tissue perfusion will help alleviate pain by promoting healing and reducing tissue damage.

B. Impaired skin integrity - Impaired skin integrity is a result of ineffective tissue perfusion. By addressing perfusion issues, skin integrity can be improved as tissues receive adequate oxygen and nutrients for healing.

C. Risk for injury - While clients with arterial insufficiency ulcers are at risk for injury, the immediate concern is addressing the ineffective tissue perfusion to prevent complications related to poor circulation, such as tissue necrosis and infection.

D. Ineffective tissue perfusion- Arterial insufficiency ulcers are caused by inadequate blood flow to the tissues. The priority issue for a client with an arterial insufficiency ulcer is ineffective tissue perfusion. Due to decreased blood flow, tissues do not receive enough oxygen and nutrients, leading to delayed wound healing, tissue damage, and potential complications. Interventions should focus on improving circulation, promoting vasodilation, and enhancing perfusion to facilitate wound healing and prevent further tissue damage.

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Naxlex Comprehensive Predictor Exams

A nurse is completing a risk assessment on a new admission. Which standardized scale will the nurse use to calculate the client's risk for pressure ulcers?

Correct Answer is B

Explanation

The nurse is caring for a client who is diagnosed with an arterial insufficiency ulcer. The nurse should plan interventions to address which priority issue?

Correct Answer is D

Explanation

A nurse is to administer one 1L bag of normal saline to a client over 5 hours. At what rate should the nurse program the pump in milliliters per hour? (Round to the whole number. Assume no interruptions.)

A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching?

A nurse is teaching a group of clients about osteoarthritis. Which of the following recommendations should the nurse include in the teaching?

A female client has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this client?

A nurse is caring for a client who is malnourished with poor skin integrity. The nurse should utilize which type of dressing to protect the client's bony prominences?

A nurse is caring for a 125 kg patient who is to receive 2.5-3.5 mg/kg of enoxaparin daily. How many milligrams will the patient receive if getting the high end of the dosage range? (Round to the whole number.)

A nurse is caring for a client who has multiple long bone fractures caused by a motor-vehicle crash that happened 24 hr ago. The client tells the nurse he is short of breath and experiencing chest pain. The nurse should assess the client further for which of the following potential complications?

The nurse is caring for an 84-year-old female client who was brought to the emergency room by her daughter, who related that her mother has had very recent mental status changes and periods of incontinence. What condition should the nurse first suspect?