A nurse is collecting data from a client following the application of a leg cast for the treatment of a fracture. Which of the following findings should the nurse expect to find first if the cast is too tight?

Toes cool to touch

Inability to move toes

Pallor of the toes

Edema of the toes

Answer and Explanation

The Correct Answer is A

The correct answer is choice A: Toes cool to touch.

Choice A rationale: When a cast is too tight, it can compromise blood circulation to the extremity. This results in decreased blood flow and reduced oxygenation, causing the toes to feel cool to the touch.

Choice B rationale: Inability to move toes is a significant concern that can also indicate nerve compression due to a tight cast. However, it may not be the first sign of a tight cast, as impaired blood circulation will likely be evident before nerve damage.

Choice C rationale: Pallor of the toes, or a pale appearance, can occur when there is restricted blood flow. However, the coolness of the toes is often noticeable before pallor develops.

Choice D rationale: Edema of the toes, or swelling, can occur due to a tight cast, but it is usually a later sign. Initially, the toes may feel cool to the touch, followed by other symptoms such as pallor, pain, and eventually, swelling.

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Correct Answer is B

Explanation

Halo-vest traction immobilizes a patient’s head and neck after traumatic injury to the cervical vertebrae as well as helping to prevent further injury to the spinal cord². Elevating the head of the bed can help improve the patient's comfort and reduce the risk of complications such as aspiration.

a. Placing the client in a supine position is not necessarily required for a patient in halo traction. The position of the patient should be determined by their individual needs and comfort.

c. Applying a pelvic girdle is not necessary for a patient in halo traction. Halo-vest traction consists of a metal ring that fits over the patient’s head and metal bars that connect the ring to a plastic vest that distributes the weight of the entire apparatus around the chest².

d. Elevating the foot of the bed is not necessary for a patient in halo traction. The position of the bed

should be determined by the patient's individual needs and comfort.

A. Peripheral edema B. Diarrhea C. Decreased pedal pulses D. Hypertension

Correct Answer is D

Explanation

A nurse collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm should monitor the client for hypertension as a manifestation of increased intracranial pressure. Increased intracranial pressure can cause changes in blood pressure, including hypertension.

a. Peripheral edema is not a manifestation of increased intracranial pressure. Peripheral edema is swelling in the extremities and can be caused by a variety of conditions.

b. Diarrhea is not a manifestation of increased intracranial pressure. Diarrhea is loose or watery stools and
can be caused by a variety of conditions.

c. Decreased pedal pulses are not a manifestation of increased intracranial pressure. Decreased pedal
pulses can indicate poor circulation to the feet and can be caused by a variety of conditions.

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A nurse is collecting data from a client following the application of a leg cast for the treatment of a fracture. Which of the following findings should the nurse expect to find first if the cast is too tight?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been placed in halo traction to immobilize his cervical spine. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Correct Answer is D

Explanation

A nurse is completing a neurovascular check for a client who had an open reduction internal fixation surgery. Which of the following findings should the nurse identify as possible manifestations of compartment syndrome? (Select all that apply)

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