A nurse is collecting data from a client who had a long arm cast applied 2 hr. ago. Which of the following findings of the affected extremity should the nurse report to the provider immediately?
The client's fingers are cool to the touch.
The client reports severe itching under the cast.
The client's capillary refill is 3 seconds.
The client reports increased pain at the area of the fracture.
The Correct Answer is A
Choice A Reason:
The client's fingers are cool to the touch is correct. Coolness of the fingers within a short time after a cast application can indicate compromised circulation or potential compartment syndrome, which requires urgent attention to prevent tissue damage or loss of function. It suggests impaired blood flow to the fingers, which is a serious concern requiring immediate evaluation by the provider.
Choice B Reason:
The client reports severe itching under the cast is incorrect. While itching can be uncomfortable, it might not pose an immediate threat. Itching can commonly occur as the skin heals and can be managed through non-invasive means.
Choice C Reason:
The client's capillary refill is 3 seconds is incorrect. A capillary refill of 3 seconds is slightly prolonged but doesn't typically indicates an immediate emergency. However, if this finding worsens or if combined with other concerning symptoms, it might warrant further assessment.
Choice D Reason:
The client reports increased pain at the area of the fracture is incorrect. Increased pain after a cast application can be expected initially, especially within 2 hours of the procedure. However, persistent or severe pain could indicate issues like poor alignment, swelling, or other complications. While it's important to address pain, it might not require immediate reporting unless accompanied by other concerning symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Speech therapists, also known as speech-language pathologists, specialize in evaluating and treating swallowing difficulties (dysphagia) among other speech and language issues. They are trained to assess and provide therapies to improve swallowing function, ensuring safe and effective swallowing to prevent aspiration and related complications.
Choice B Reason:
Respiratory therapists primarily focus on the respiratory system and breathing issues. While they play a crucial role in managing respiratory problems, their expertise generally centers around respiratory treatments, ventilator management, and pulmonary function testing. They might assist if dysphagia leads to aspiration and subsequent respiratory complications, but the primary management of dysphagia itself falls within the scope of a speech therapist.
Choice C Reason:
Occupational therapists assist individuals in regaining independence in daily activities. While they may help with certain aspects of dysphagia management, their primary focus isn't specifically on evaluating and treating swallowing disorders. They might address related issues, such as adapting eating utensils or positioning during meals to assist the client, but they may not have the specialized training needed for direct dysphagia therapy.
Choice D Reason:
Physical therapists primarily focus on improving mobility, strength, and physical function. While they might address certain issues related to oral motor function or posture during eating that could affect swallowing, their expertise lies more in physical rehabilitation rather than the specialized treatment of dysphagia.
Correct Answer is A
Explanation
Choice A Reason:
Administering a prescribed oral dose of trazodone to the client is correct. Trazodone is sometimes used to manage agitation in patients with Alzheimer's disease, as it has calming effects and can help reduce agitation and anxiety. However, the use of any medication should be based on the client's individualized treatment plan and prescribed by a healthcare provider.
Choice B Reason:
Encouraging ambulation might not be suitable if the client is agitated, as it could potentially escalate the situation or increase the risk of falls or injury. Safety should be a priority, and ambulation might not be advisable during a state of agitation.
Choice C Reason:
Isolating the client in their room is incorrect. Isolating the client might increase feelings of confusion, fear, or distress, potentially worsening the agitation. It's important to engage and support the client rather than isolate them, which can be distressing for someone with Alzheimer's disease.
Choice D Reason:
Applying bilateral wrist restraints to the client is incorrect. The use of restraints should only be considered as a last resort when all other measures have failed and when there's an immediate risk of harm to the client or others. Restraints can be physically and psychologically harmful, leading to increased agitation, anxiety, and potential injury. They should be used only under strict guidelines and with proper authorization when all other interventions have been exhausted.
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