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The client is avoiding eye contact with staff and is more withdrawn.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 A
Explanation
Choice A rationale
Asking about the content of the voices helps the nurse assess for command hallucinations, which can pose a safety risk to the client or others. This open-ended question encourages the client to elaborate, providing crucial information about the severity, nature, and potential danger of the auditory stimuli, which is the primary goal of the assessment.
Choice B rationale
This question is counterproductive because it asks for a causal explanation that the client, due to their altered neurochemical state, cannot provide. It can also be perceived as challenging the reality of the client's experience, which invalidates their feelings and can damage the therapeutic relationship. This is not a therapeutic approach.
Choice C rationale
This redirects the conversation away from the client's immediate distress and the core issue of their hallucinations. While therapy is part of treatment, it may not be appropriate at this moment of crisis. The nurse’s priority is to first assess the immediate risk and support the client's immediate needs, before introducing another activity.
Choice D rationale
Asking about medication adherence can be perceived as accusatory and may cause the client to become defensive. While medication non-adherence can contribute to symptom exacerbation, the immediate priority is to assess the current risk level posed by the hallucinations, not to lecture the client about medication. This question is not therapeutic.
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