A client who has a compound fracture of the right tibia has a long-leg fiberglass cast. To reinforce teaching for the client about how to observe and manage his fracture at home, the nurse should include which of the following instructions?
Use a blow dryer on a moderate heat setting to dry the cast after showering.
Use a cotton swab to relieve itching under the cast
Report any worsening or unrelieved pain.
Avoid moving the affected leg.
The Correct Answer is C
A. Use a blow dryer on a moderate heat setting to dry the cast after showering.
This is not recommended as using a blow dryer on a cast can cause burns. Instead, the cast should be allowed to air-dry or be dried with a fan.
B. Use a cotton swab to relieve itching under the cast.
Inserting objects, including cotton swabs, under the cast can lead to complications such as infection or skin damage. It is not recommended to insert anything into the cast.
C. Report any worsening or unrelieved pain.
This is the correct instruction. Persistent or increasing pain can indicate complications such as swelling, infection, or neurovascular compromise. It is important for the client to promptly report any changes in pain to healthcare providers.
D. Avoid moving the affected leg.
While it's important to limit movement to allow for proper healing, complete immobilization can lead to joint stiffness and muscle atrophy. Gentle range-of-motion exercises for non-weight-bearing areas may be encouraged, but any specific movement instructions should be provided by the healthcare provider. If movement causes significant pain or discomfort, the client should consult the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Stress incontinence
Stress incontinence is the involuntary loss of urine during activities that increase intra-abdominal pressure, such as sneezing, coughing, laughing, or lifting heavy objects. In stress incontinence, the pelvic floor muscles are weakened, leading to inadequate support of the bladder and urethra. This results in leakage of urine during moments of increased pressure on the bladder.
B. Urge incontinence
Urge incontinence involves a strong and sudden urge to urinate, leading to involuntary urine loss. It is often associated with an overactive bladder and may not be related to increased abdominal pressure.
C. Overflow incontinence
Overflow incontinence occurs when the bladder is unable to empty completely, leading to constant dribbling of urine. It is often associated with conditions that obstruct urine flow, such as an enlarged prostate in men.
D. Reflex incontinence
Reflex incontinence is characterized by the involuntary loss of urine due to a reflex arc that bypasses normal control mechanisms. It is often associated with neurological conditions that affect bladder control.
Correct Answer is C
Explanation
A. To help the nurse validate the client’s reports of pain
This option suggests that the nurse's actions (straightening bed linens, rubbing the back, assisting with repositioning) are intended to assess or confirm the client's reports of pain. However, these actions are more aligned with providing comfort and assistance with activities of daily living rather than specifically assessing pain. If the client reports pain related to the chest tube, a more focused assessment and intervention would be needed.
B. To increase positive pressure in the chest
This option implies that the nurse's actions could somehow influence the positive pressure in the client's chest, which is not accurate. Positive pressure in the chest is usually related to mechanical ventilation or specific medical interventions. The described actions are more related to comfort and assistance with daily activities.
C. To assist the client with ADLs (Activities of Daily Living)
This is the most appropriate choice. The nurse's actions, such as straightening bed linens, rubbing the back, and assisting with repositioning, align with providing support for the client's daily activities and overall well-being.
D. To modify the client’s perception of pain
This option suggests that the nurse's actions are aimed at altering the client's perception of pain. While comfort measures can contribute to pain management, these specific actions are not typically used to modify perception. If pain is a concern, more direct pain management strategies and assessments would be appropriate.
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