A nurse is caring for a client.
Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.
|
Body system |
Findings |
|
Neurologic |
Client is awake, alert, oriented x3 |
|
Cardiovascular |
Client reports no palpitations, heart rhythm regular. Right lower extremity +2 edema from ankle to below the knee joint. Skin warm and inflamed: +2 pedal pulses present in bilateral extremities |
|
Musculoskeletal |
Client reports no groin pain, has slight limp with weight bearing on the right extremity |
Client is awake, alert, oriented x3
Client reports no palpitations, heart rhythm regular.
Right lower extremity +2 edema from ankle to below the knee joint.
Skin warm and inflamed
has slight limp with weight bearing on the right extremity
The Correct Answer is ["C","D","E"]
Rationale for correct choices
• Right lower extremity +2 edema from ankle to below knee: This level of edema in one limb suggests impaired venous return and is a key indicator of possible deep vein thrombosis. Unilateral swelling that develops with reduced mobility places the client at higher risk and warrants immediate assessment. Early detection is important to prevent progression to pulmonary embolism.
• Skin warm and inflamed on right lower extremity: Localized warmth and inflammation are hallmark findings of venous thrombosis or inflammatory processes in the limb. The client’s sedentary pattern and unilateral symptoms strengthen the suspicion of a vascular complication. Prompt evaluation helps guide diagnostic testing such as Doppler ultrasound.
• Slight limp with weight bearing on right extremity: A new limp combined with swelling and inflammation suggests evolving pain or functional impairment. This may indicate deep venous obstruction, localized inflammation, or injury exacerbated by reduced mobility.
Rationale for incorrect choices
• Client is awake, alert, oriented x3: This indicates intact neurological status and does not require follow-up at this time. The client shows no evidence of cognitive changes, syncope, or neurological compromise.
• Client reports no palpitations, heart rhythm regular: A regular heart rhythm without palpitations suggests stable cardiovascular status. There are no immediate arrhythmia-related concerns requiring follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","F"]
Explanation
Rationale:
A. Explain the cast application procedure to the child: Preparing the child for a future procedure is helpful but not immediately necessary. At this point, pain control and reduction of swelling take precedence to prevent complications and stabilize the injury.
B. Review cast care instructions with the child's parents: While parent education is important, it is secondary to immediate interventions that address pain, swelling, and preparation for the procedure. Priority actions focus first on the child’s current needs and safety.
C. Elevate the affected forearm with pillows: Elevation helps reduce edema and pain in the fractured extremity and prevents further swelling. This is a critical nursing intervention for acute fracture management before and after casting.
D. Apply ice packs to the fingers and along the right forearm: Ice helps manage pain and inflammation by vasoconstriction, limiting fluid accumulation in tissues. Applying it early post-injury is crucial to controlling swelling in a fractured limb.
E. Place a nonadherent dressing on the right knee abrasion: Caring for minor abrasions is important but is not a priority compared with interventions addressing fracture management, pain, and preparation for cast application.
F. Administer Ibuprofen 200 mg PO: Pain management is a priority in fracture care to maintain comfort and reduce distress. Administering analgesics before cast application helps the child tolerate the procedure and facilitates cooperation.
Correct Answer is D
Explanation
Rationale:
A. "Why did you start drinking alcohol?": This question explores motivations or personal history but is not part of the standardized Alcohol Use Disorders Identification Test (AUDIT). The AUDIT focuses on quantity, frequency, and consequences of alcohol use rather than reasons for drinking.
B. "Does anyone else in your family have a drinking problem?": Family history of alcohol use may be relevant for overall assessment but is not included in the AUDIT, which is designed to screen the client’s own drinking behaviors and risks.
C. "How old were you when you started to drink alcohol?": Age of initiation provides background information but is not a question within the AUDIT. The test is concerned with current patterns and consequences of alcohol consumption.
D. "How often do you drink alcohol?": This question is a standard component of the AUDIT and assesses the frequency of alcohol consumption. It helps identify patterns of use and potential risk for alcohol-related problems, making it appropriate for inclusion in the screening.
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