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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should use the term "postictal phase" when documenting the client's difficulty arousing and sleepiness for several hours following a generalized tonic-clonic seizure. The postictal phase is the period of time immediately following a seizure during which the client may be difficult to arouse and very sleepy.
Presence of absence seizures, presence of automatisms, and aura phase are not appropriate descriptions for the nurse to use when documenting this finding in the medical record. Absence seizures are a type of seizure characterized by brief episodes of staring and unresponsiveness. Automatisms are repetitive, unconscious movements that can occur during a seizure. The aura phase is a warning sign that can occur before a seizure.
Correct Answer is A
Explanation
a.A GCS score of 8 indicates severe impairment, suggesting the client may be in a state where they cannot perform basic self-care activities and thus require total nursing care.
b.A GCS score of 8 indicates severe impairment but not necessarily a deep coma. Scores below 8 suggest a comatose state, but deep coma is more likely to be indicated by a score of 3-4.
c.A GCS score of 8 is not consistent with a client who is alert and oriented. This score indicates significant neurological impairment.
d.A GCS score of 8 does not indicate stable neurological status. It suggests severe impairment and potentially unstable or deteriorating neurological condition.
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