A nurse is caring for a client following an open reduction and internal fixation of a fractured femur.
Which of the following findings is the nurse's priority?
Headache.
Altered level of consciousness.
Muscle spasms.
Oral temperature of 37.7C (99.86F).
The Correct Answer is B
Choice A rationale
Headache could indicate various conditions but is not immediately life-threatening post-surgery. It may be due to medication or anesthesia but is not the priority.
Choice B rationale
Altered level of consciousness (LOC) is a critical finding. It may indicate complications such as hemorrhage, fat embolism, or hypoxia, which require urgent assessment and intervention.
Choice C rationale
Muscle spasms can be a common symptom post-surgery due to pain or positioning. While they need management, they do not take precedence over LOC changes.
Choice D rationale
An oral temperature of 37.7°C is slightly elevated but not alarming. It may be due to the body's normal inflammatory response post-surgery.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Autonomy vs. shame and doubt is the stage for toddlers, where children learn to assert their independence and autonomy. This stage doesn't apply to school-age children.
Choice B rationale
Identity vs. role confusion is the stage for adolescents, where they explore different roles and integrate them into their identity. This is beyond the scope of school-age children.
Choice C rationale
Initiative vs. guilt applies to preschool children, where they begin to assert power and control through directing play and other social interactions. School-age children have moved past this stage.
Choice D rationale
Industry vs. inferiority is the stage for school-age children according to Erikson's theory. In this stage, children develop a sense of pride and competence in their skills and abilities through school and social interactions.
Correct Answer is A
Explanation
Choice A rationale
Asymmetric thigh folds are a common sign of developmental dysplasia of the hip (DDH) in infants. This physical examination finding indicates that the hips are not aligned properly, which can cause the folds in the thighs to appear uneven.
Choice B rationale
A shortened thigh, rather than a lengthened one, on the affected side is more typical of DDH. It is due to the femoral head not being properly seated in the hip socket, which can cause a discrepancy in leg length.
Choice C rationale
An inwardly turned foot is not a characteristic finding of DDH. This symptom is more commonly associated with conditions affecting the feet and lower legs, such as clubfoot.
Choice D rationale
The absence of plantar reflexes is not typically associated with DDH. This reflex involves a different part of the nervous system and is not linked to hip dysplasia.
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