A nurse is caring for a client who has musculoskeletal injuries to the left lower extremity. Which of the following assessments should the nurse perform to evaluate the neurovascular status of the client's extremity?

Check skin temperature distal to the injury with the dorsum of the hand.

Press the heel of the foot to determine capillary refill.

Monitor sensation by palpating the pad of the great toe with a blunt needle.

Compare the color of the skin proximal to the injury with the other extremity.

Answer and Explanation

The Correct Answer is A

A. Check skin temperature distal to the injury with the dorsum of the hand.: Assessing skin temperature distal to the injury is an important part of evaluating neurovascular status. It helps to identify any changes in circulation or potential complications like ischemia. The dorsum of the hand is commonly used as it provides a good comparison to the temperature of the affected extremity.

B. Press the heel of the foot to determine capillary refill.: While capillary refill is an important assessment, it is usually measured by pressing the nail beds or pads of the fingers and toes, not by pressing the heel. This method does not provide a reliable indication of neurovascular status.

C. Monitor sensation by palpating the pad of the great toe with a blunt needle.: While assessing sensation is important, it is typically done using a light touch or pinprick, rather than palpating with a blunt needle. The use of a needle is not standard practice for this type of assessment.

D. Compare the color of the skin proximal to the injury with the other extremity.: Comparing the skin color distal to the injury with the unaffected extremity is more relevant for evaluating neurovascular status. Proximal comparison is less effective in assessing circulation and potential issues related to the injury.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A) "I have been taking acetaminophen when my knees start to hurt.":
Taking acetaminophen for pain relief indicates that the client is managing the osteoarthritis symptoms appropriately. Acetaminophen is a recommended first-line treatment for mild to moderate pain associated with osteoarthritis and can help improve the client's quality of life by reducing discomfort.

B) "I've been sleeping on my back with a large pillow under my knees.":
Sleeping with a large pillow under the knees can cause the knees to remain in a flexed position for prolonged periods, potentially leading to joint stiffness and worsening pain. This practice is not typically recommended for clients with osteoarthritis as it can exacerbate symptoms.

C) "I have been exercising every day, even when I have pain.":
While regular exercise is beneficial for managing osteoarthritis, it is important to avoid exercising through significant pain. Pain during exercise may indicate overuse or joint damage. Clients should be encouraged to modify their activities to prevent further joint stress and manage symptoms effectively.

D) "I've been changing my lidocaine patches every 18 hours.":
Lidocaine patches are typically designed for 12-hour application periods, followed by a 12-hour off period. Changing the patches every 18 hours may not provide the intended relief and could lead to inconsistent pain management. Proper use of pain management techniques is essential for effective disease management.

A. Double-bag the client's trash before removing it from the room. B. Place the client in a negative air pressure room with 6 to 12 air exchanges per hour. C. Ensure all air in the client's room is filtered through a HEPA filter. D. Wear a surgical mask when within 1 m (3 ft) of the client.

Correct Answer is D

Explanation

A) Double-bag the client's trash before removing it from the room: Double-bagging trash is typically recommended for patients with highly contagious and severe infectious diseases, such as those requiring contact precautions. Influenza, while contagious, does not necessitate this level of precaution.

B) Place the client in a negative air pressure room with 6 to 12 air exchanges per hour: Negative air pressure rooms are used for airborne diseases like tuberculosis or measles, which can spread through the air over long distances. Influenza primarily spreads through respiratory droplets, so this precaution is not necessary.

C) Ensure all air in the client's room is filtered through a HEPA filter: HEPA filters are used for airborne pathogens to filter out infectious particles. Since influenza spreads via respiratory droplets rather than airborne particles, this level of air filtration is not required.

D) Wear a surgical mask when within 1 m (3 ft) of the client: Influenza spreads through respiratory droplets, which can travel up to about 1 meter (3 feet) when a person coughs or sneezes. Wearing a surgical mask within this distance helps prevent inhalation of these droplets, making it the appropriate precaution for influenza.

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