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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Watermelon with seeds poses a choking hazard for young children, making it an unsafe food choice. The seeds can easily get stuck in a child’s throat, leading to potential airway obstruction. Additionally, small children might not have the coordination to properly spit out seeds, increasing the risk of accidental swallowing and subsequent choking. Therefore, whole fruits with seeds are generally recommended to be avoided for toddlers.
Choice B rationale
Raw carrots are another choking hazard for young children due to their hard texture. Toddlers might not have developed the necessary chewing skills to safely eat raw vegetables, increasing the risk of choking. Small, hard foods like raw carrots can be difficult to chew and swallow, making them unsafe for children under the age of three. Cooked or finely chopped vegetables are safer alternatives.
Choice C rationale
Mashed potatoes are a safe and appropriate food choice for a 14-month-old child. They are soft, easy to chew, and swallow, reducing the risk of choking. Mashed potatoes can be easily modified to suit the nutritional needs and texture preferences of young children. They can also be fortified with other healthy ingredients like pureed vegetables or proteins to make a balanced meal for toddlers.
Choice D rationale
Popcorn is a known choking hazard for young children and is not recommended for those under the age of four. Popcorn kernels are small, hard, and irregularly shaped, making them difficult for young children to chew and swallow safely. The risk of choking on popcorn is high due to its propensity to lodge in the airway, causing potentially serious complications. .
Correct Answer is A
Explanation
Choice A rationale
Push-pull toys help with walking development and coordination, suitable for an 11-month-old who is likely starting to take their first steps.
Choice B rationale
Large-piece puzzles are more appropriate for older toddlers who have developed better fine motor skills and problem-solving abilities.
Choice C rationale
Crib gyms are more suited for younger infants who spend more time lying down and can benefit from reaching and batting at toys.
Choice D rationale
Coloring books with crayons are best for older toddlers who have better control over their hand movements and can safely use small objects like crayons.
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