A nurse is caring for an adolescent client who has a fractured right tibia and a cast. Which of the following findings should the nurse report to the provider?
Pain following range-of-motion exercises.
Pruritus under the cast.
Presence of swelling while the extremity is dependent.
Coolness of the toes.
The Correct Answer is A
Choice A rationale:
Pain following range-of-motion exercises is a significant finding that should be reported to the provider. It could indicate the possibility of complications, such as further injury or impaired healing. Adolescents with fractured bones are often encouraged to perform range-of-motion exercises to prevent stiffness and promote circulation. However, increased pain during or after these exercises could indicate problems like muscle strain or improper alignment of the fracture, which need to be addressed promptly.
Choice B rationale:
Pruritus (itching) under the cast is common and can be expected due to the accumulation of dead skin cells and sweat. While it can be uncomfortable for the client, it's not an urgent concern that requires immediate reporting to the provider. Strategies to alleviate itching, such as using a cool blow dryer under the cast, can be taught to the client.
Choice C rationale:
The presence of swelling while the extremity is dependent is a normal response to gravity and is not an alarming finding. Swelling when the extremity is dependent is expected, especially within the initial stages of fracture healing. It suggests that the blood supply is reaching the area for healing purposes. Elevation and rest can help reduce the swelling.
Choice D rationale:
Coolness of the toes could be due to reduced blood flow, but this finding alone may not be an immediate concern. It's essential to consider the client's overall circulation, capillary refill, and presence of pulses. If other signs of impaired circulation, such as pallor or delayed capillary refill, are present along with coolness, it might indicate compromised vascular supply. However, based on the information provided, this choice is not as urgent as reporting pain following range-of-motion exercises.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
After a tonic-clonic seizure, it's common for the person to inadvertently bite their tongue, cheeks, or lips during the convulsive movements. Checking the mouth for any signs of bleeding or injuries is essential to ensure the person's safety and provide appropriate care.
Choice B rationale:
Placing the child's head in a hyperextended position is not recommended after a seizure. In fact, it's important to keep the person's head and neck in a neutral position to prevent potential injury. Hyperextending the neck could lead to strain or other complications.
Choice C rationale:
Giving the child a drink of water immediately after a seizure is not necessary and might be unsafe. The child may still be disoriented or have difficulty swallowing immediately after the seizure. It's best to ensure the child's safety and monitor their condition before offering any fluids.
Choice D rationale:
Administering naloxone intramuscularly is not indicated for a tonic-clonic seizure. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose. Seizures have a different underlying cause, and administering naloxone would not be effective or appropriate in this context.
Correct Answer is A
Explanation
Choice A rationale:
The FLACC (Face, Legs, Activity, Cry, Consolability) scale is a pain assessment tool commonly used for infants and young children who cannot verbalize their pain. It assesses different behavioral and physiological indicators of pain, such as facial expressions, leg movement, activity level, crying, and response to consoling. Given that the infant is only 18 months old, this scale is appropriate for evaluating their postoperative pain.
Choice B rationale:
The Color tool is not a recognized pain assessment tool. It's essential to use validated and standardized pain assessment scales, and the Color tool does not fit this criterion.
Choice C rationale:
The Poker Chip Tool is not typically used for pain assessment in infants. It's often used with older children to assess pain intensity using a poker chip set that corresponds to different levels of pain. However, for an 18-month-old infant, behavioral assessments like the FLACC scale would be more suitable.
Choice D rationale:
The Numeric scale involves asking the patient to rate their pain on a numerical scale, often from 0 to 10. However, this scale is not appropriate for an 18-month-old infant who is likely unable to comprehend or use numbers to express their pain. The FLACC scale provides a more comprehensive assessment of pain in non-verbal or preverbal children.
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