A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?

Palpate the pulse distal to the cast.

Position the casted extremity on a pillow.

Place an ice pack over the cast.

Teach the client to keep the cast clean and dry.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Palpate the pulse distal to the cast: Assessing neurovascular status is the priority immediately after cast application. Palpating the distal pulse helps determine adequate circulation and can detect complications like compartment syndrome early, which can lead to permanent damage if untreated.

B. Position the casted extremity on a pillow: Elevating the extremity helps reduce swelling and pain, but it is a secondary action. Ensuring perfusion through a pulse check takes precedence before supportive comfort measures are initiated.

C. Place an ice pack over the cast: Cold therapy can help minimize swelling and pain in the initial hours after casting, but it should only be done after confirming that circulation is intact. Ice packs should also be used carefully to prevent moisture from damaging the cast.

D. Teach the client to keep the cast clean and dry: Education is important for long-term cast care, but it is not the immediate priority after application. Early assessment for circulation, sensation, and movement must occur first to ensure the cast has not compromised perfusion.

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Free Nursing Study Resources

Correct Answer is {"B":{"answers":"A"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

Rationale:

Bloody stools: Bloody stools are not a typical finding in either acute pancreatitis or peritonitis. They are more commonly associated with lower GI pathologies such as diverticulosis, hemorrhoids, or inflammatory bowel disease. Their absence here does not support either condition.
Hyperbilirubinemia: Hyperbilirubinemia (total bilirubin 3.7 mg/dL) may occur with pancreatitis, especially if there is biliary obstruction due to inflammation or gallstones. Obstructed bile flow leads to accumulation of bilirubin, causing jaundice as seen in this client’s yellow sclera and palate.
Elevated WBC count: Leukocytosis (WBC 18,000/mm³) is a systemic inflammatory response commonly seen in both acute pancreatitis and peritonitis. In pancreatitis, this reflects the inflammatory process of autodigestion of the pancreas. In peritonitis, it reflects infection and inflammation of the peritoneal cavity.
Abdominal pain: Severe abdominal and epigastric pain radiating to the back is classic for acute pancreatitis. Peritonitis can also cause diffuse abdominal pain with guarding and rigidity, particularly when the peritoneum becomes inflamed. The pain in peritonitis often worsens with movement, while pancreatitis pain may worsen with eating or lying flat.

A. The client slept 5 hr the previous night. B. The client consumes 8 oz of high-calorie fluids each hour. C. The client takes short naps during the day. D. The client engages in quiet activities in their room E. The client appears to listen to unseen others.

Correct Answer is ["A","B","D"]

Explanation

Rationale:

A. The client slept 5 hr the previous night: Restorative sleep reflects stabilization in manic episodes, where insomnia is a key symptom. Sleeping for five hours is a significant improvement, indicating reduced hyperactivity and improved mood regulation.

B. The client consumes 8 oz of high-calorie fluids each hour: Adequate nutritional intake and hydration are often compromised in mania due to distractibility and hyperactivity. Regular consumption of fluids shows enhanced attention, cooperation, and reduced psychomotor agitation.

C. The client takes short naps during the day: Napping during the day may actually signal persistent hyperactivity or fragmented sleep cycles. Restful, consolidated nighttime sleep is a better indicator of clinical improvement than sporadic daytime naps.

D. The client engages in quiet activities in their room: Participation in low-stimulation activities reflects improved impulse control, attention span, and reduced need for excessive stimulation positive signs of response to lithium and therapeutic interventions.

E. The client appears to listen to unseen others: Persistent auditory hallucinations suggest ongoing psychotic features. Although lithium can reduce mood-related psychosis, hallucinations at this stage indicate incomplete resolution of manic or psychotic symptoms.

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A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"B":{"answers":"A"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

The nurse is continuing to care for the client. Exhibits The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

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