A nurse is assessing a client who has a hip fracture. Which of the following findings should the nurse expect?
Muscle spasms
Hip pallor
Leg abduction
Leg lengthening
The Correct Answer is A
A. Muscle spasms can occur in response to the hip fracture as the body attempts to protect the injured area. Spasms may cause pain and muscle rigidity in the affected hip.
B. Pallor refers to paleness of the skin. While hip fractures can result in various signs and symptoms such as pain, swelling, and bruising, hip pallor specifically is not typically associated with a hip fracture.
C. Leg abduction refers to moving the leg away from the midline of the body. In the case of a hip fracture, the affected leg may be held in adduction (closer to the midline) due to pain and muscle guarding.
D. Leg lengthening is not typically associated with a hip fracture. In fact, a hip fracture can often lead to apparent leg shortening due to displacement or angulation of the fractured bone.
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Related Questions
Correct Answer is B
Explanation
B. Muscle spasms can sometimes be triggered or exacerbated by poor positioning or pressure on certain areas of the body. Realigning the client's position will help relieve muscle spasms by reducing pressure or tension on the affected muscles.
A. Adjusting the weight amount in traction may help alleviate pain and muscle spasms by reducing tension on the affected limb. However, realignment should be done first.
C. Muscle relaxants can help alleviate muscle spasms and associated pain by reducing muscle tone and tension. However, realignment should be done first.
D. Opioid analgesics are potent pain relievers that can effectively manage moderate to severe pain, including pain from muscle spasms. However, that should not be the first intervention.
Correct Answer is C
Explanation
C. A neurovascular assessment involves evaluating the circulation, sensation, and movement of the limb distal to the cast to ensure there are no signs of neurovascular compromise, such as decreased pulses, numbness, tingling, or weakness. Prompt identification of any neurovascular impairment is essential for preventing complications such as compartment syndrome.
A. Explaining discharge instructions is important for ensuring the client and their parents understand how to care for the cast at home. However, it is not the priority action.
B. Applying an ice pack to the casted leg can help reduce swelling and provide pain relief, but it is not the priority action immediately after the cast application.
D. Providing reassurance is important for alleviating anxiety and promoting a positive experience for the client and their parents. However, it is not the priority action.
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