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

Answer and Explanation

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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Correct Answer is C

Explanation

C. The patient's calf being swollen and warm to touch is concerning for a possible deep vein thrombosis (DVT), a clot formation in the deep veins of the leg. DVT is a serious complication post-surgery that requires immediate attention to prevent the clot from dislodging and causing a pulmonary embolism (PE), which can be life-threatening.

A. Abdominal pain after a total abdominal hysterectomy is common and can be expected due to the surgical incision and manipulation of abdominal tissues.

B. Fluid balance is important postoperatively to prevent complications like dehydration or fluid overload. A significant imbalance, with intake substantially greater than output, could indicate issues which may require intervention. However, this is not as urgent as a client with likely DVT.

D. A slight increase in temperature is common in the immediate postoperative period due to the body's response to tissue injury. While it could indicate infection, it's not necessarily alarming on its own.

A. Cool extremities B. Positive Phalen's sign C. Positive Trousseau's sign D. Decreased radial pulse

Correct Answer is B

Explanation

B. Phalen's sign is a test for carpal tunnel syndrome. It is positive when the client experiences numbness, tingling, or pain in the median nerve distribution (especially the thumb, index finger, middle finger, and half of the ring finger) within 1 minute of wrist flexion.

A. Cool extremities are not typically associated with carpal tunnel syndrome. They may indicate issues related to circulation rather than compression of the median nerve.

C. Trousseau's sign is a test for latent tetany, which is associated with hypocalcemia. It involves inflating a blood pressure cuff on the upper arm and observing for carpal spasm. It is not a manifestation of carpal tunnel syndrome.

D. A decreased radial pulse may indicate vascular issues or compression of the radial artery, not carpal tunnel syndrome.

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A nurse is assessing a client who has a hip fracture. Which of the following findings should the nurse expect?

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