A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?
Provide reassurance to the client and parents.
Perform a neurovascular assessment.
Apply an ice pack to the casted leg
Explain the discharge instructions to the client and parents.
The Correct Answer is B
A. Provide reassurance to the client and parents: While reassurance is important, it is not the priority action when caring for an adolescent client with a newly applied fiberglass cast for a fractured tibia. Ensuring adequate neurovascular status is critical to prevent complications associated with impaired circulation or nerve function.
B. Perform a neurovascular assessment: This is the correct action and the priority when caring for a client with a newly applied cast. The nurse should assess the client's neurovascular status by evaluating circulation, sensation, and movement distal to the casted limb. Changes in color, temperature, sensation, or movement could indicate impaired circulation or nerve function, which require immediate intervention to prevent complications such as compartment syndrome.
C. Apply an ice pack to the casted leg: While applying ice may help reduce swelling and discomfort, it is not the priority action when caring for a client with a newly applied cast. Additionally, applying ice directly to the cast may not effectively reach the skin and underlying tissues, potentially causing discomfort without providing significant benefit.
D. Explain the discharge instructions to the client and parents: Providing discharge instructions is important for client education, but it is not the priority action immediately after applying a cast. Ensuring the client's safety and well-being by performing a neurovascular assessment takes precedence to identify and address any potential complications associated with the cast.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Intermittent abdominal pain following passage of bloody mucus: This description is more consistent with the symptoms of placental abruption, where there is painful bleeding with the passage of blood and mucus. Placenta previa typically presents with painless bleeding.
B. Increasing abdominal pain with a non-relaxed uterus: Increasing abdominal pain with a non-relaxed uterus suggests uterine irritability, which may be indicative of preterm labor rather than placenta previa. Placenta previa typically presents with painless bleeding.
C. Painless red vaginal bleeding: This finding is characteristic of placenta previa. Pain is typically absent or minimal with placenta previa, and the bleeding is bright red due to the richly oxygenated maternal blood flowing from the placental vessels.
D. Abdominal pain with scant red vaginal bleeding: While abdominal pain may occur in some cases of placenta previa, it is typically not the predominant symptom. Additionally, the bleeding associated with placenta previa is typically painless and can be more profuse than scant bleeding.
Correct Answer is ["B","D","E"]
Explanation
A. Fine hand tremors and pill rolling: These symptoms are more indicative of parkinsonism, which is another extrapyramidal side effect of antipsychotic medications but not specifically tardive dyskinesia.
B. Facial grimacing and eye blinking: Facial grimacing and eye blinking are classic signs of tardive dyskinesia. These involuntary movements of the face are often seen in patients who have been on antipsychotic medications for an extended period.
C. Urinary retention and constipation: Urinary retention and constipation are not typically associated with tardive dyskinesia. These symptoms may be related to other medication side effects or unrelated conditions.
D. Involuntary pelvic rocking and hip thrusting movements: These movements are characteristic of tardive dyskinesia. Involuntary pelvic rocking and hip thrusting can occur as part of the abnormal involuntary movements seen in tardive dyskinesia.
E. Tongue thrusting and lip smacking: Tongue thrusting and lip smacking are classic signs of tardive dyskinesia, particularly involving the orofacial region. These movements can be distressing for patients and may interfere with speech and eating.
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