A client reports pain worsening in their right forearm, rating the pain as 7 on a scale of 0 to 10. The client also states their right hand is "tingly.”. The client is able to move their fingers.
The client is avoiding eye contact with staff and is more withdrawn.
The client's adult child is at the bedside.
The client appears drowsy and less alert, but is oriented to person, place, time, and situation.
The client's apical pulse is regular, and their lungs are clear to auscultation.
A report is given to the operating room nurse, and the client is en route to the surgical suite via gurney for repair of a right radial fracture.
Encourage the client to ambulate to the bathroom.
Check the client's peripheral pulses and capillary refill.
Elevate the client's arm above the level of the heart.
Administer a sedative to help the client relax.
The Correct Answer is B
Choice A rationale
Encouraging the client to ambulate to the bathroom would be inappropriate and potentially harmful. The client is experiencing worsening pain, tingling, and is on a gurney en route to surgery for a fractured radius. Ambulation could exacerbate the injury, increase pain, and risk further complications. Mobility should be restricted until the fracture is stabilized and the client is post-operative.
Choice B rationale
This is the correct action as it assesses for potential complications of compartment syndrome, a critical and urgent condition. The worsening pain and tingling are classic symptoms. Compartment syndrome occurs when pressure builds within the fascial compartments, compromising circulation. A loss of peripheral pulses and delayed capillary refill are late signs of impaired circulation and are key indicators for this limb-threatening emergency.
Choice C rationale
Elevating the arm above the heart would decrease arterial blood flow to the injured extremity, which could worsen tissue perfusion and potentially lead to ischemia. For a client with a suspected circulatory compromise, such as with compartment syndrome, the arm should be kept at the level of the heart to maintain adequate blood flow.
Choice D rationale
Administering a sedative could mask the client's symptoms, particularly the level of pain and changes in mental status, which are crucial indicators of their deteriorating condition. The client's pain is a vital sign that needs to be continuously monitored, and sedation would hinder the nurse's ability to accurately assess for changes in their neurovascular status. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
This location, the second intercostal space at the right sternal border, corresponds to the aortic valve area. Auscultation here allows the nurse to assess the sounds produced by the aortic valve, which are distinct from the mitral valve sounds. These sounds are generated as blood is ejected from the left ventricle into the aorta during systole.
Choice B rationale
The second intercostal space at the left sternal border is the correct anatomical location for auscultating the pulmonic valve. The pulmonic valve separates the right ventricle from the pulmonary artery, and listening here allows the nurse to assess the sounds of blood flow into the pulmonary circulation.
Choice C rationale
The fifth intercostal space at the left midclavicular line is the point of maximal impulse (PMI), also known as the apical pulse, which is the anatomical location for the mitral valve. This is the optimal site for auscultating the S1 and S2 heart sounds, as well as any murmurs or abnormal sounds associated with the mitral valve's function.
Choice D rationale
This location, the fourth intercostal space at the left sternal border, is the anatomical location for the tricuspid valve. Auscultation in this area allows the nurse to assess the sounds generated by the tricuspid valve, which regulates blood flow between the right atrium and the right ventricle. *.
Correct Answer is C
Explanation
Choice A rationale
Increased head circumference is an unexpected finding in a newborn exposed to cocaine in utero. Cocaine is a potent vasoconstrictor, which reduces blood flow and oxygen to the developing fetus, potentially leading to intrauterine growth restriction, which would more likely result in a smaller head circumference, not a larger one. This is due to compromised fetal oxygenation and nutrient delivery.
Choice B rationale
Hypotonicity, or decreased muscle tone, is not a typical finding. Neonates exposed to cocaine in utero often exhibit hypertonicity and a rigid posture due to central nervous system excitability. This increased muscle tone is a common neurological manifestation resulting from the drug's stimulatory effects on the developing nervous system, leading to hyperirritability and tremors.
Choice C rationale
Irritability is a very common finding in a newborn exposed to cocaine throughout pregnancy. Cocaine is a potent central nervous system stimulant, and its effects on the developing fetal brain can lead to long-term neurological and behavioral issues. After birth, the neonate experiences withdrawal symptoms, resulting in excessive crying, high-pitched cries, tremors, and a state of hypervigilance.
Choice D rationale
A decreased auditory startle response is not an expected finding. Newborns exposed to cocaine often exhibit an increased and exaggerated startle response to various stimuli, including auditory cues. This hyperresponsiveness is a manifestation of the generalized central nervous system excitability caused by the chronic prenatal exposure to the potent sympathomimetic effects of cocaine on the brain. *.
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