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 D
Explanation
Choice A Reason:
Encouraging three large meals daily might not be feasible for someone experiencing malnutrition and decreased appetite. Smaller, more frequent meals or snacks throughout the day could be better tolerated and more beneficial.
Choice B Reason:
Administering an antiemetic after each meal assumes that the client will experience nausea or vomiting regularly after eating. This might not be the case for all clients with AIDS and may not be necessary if the primary issue is malnutrition without associated frequent vomiting.
Choice C Reason:
Seasoning foods with spices might improve the taste of food and potentially stimulate appetite, but it's not as direct or comprehensive a measure for addressing malnutrition as providing a high-calorie diet.
Choice D Reason:
Provide a high-calorie diet is correct. Clients with AIDS often experience malnutrition due to various factors such as decreased appetite, difficulty eating, or malabsorption. Offering a high-calorie diet can help address nutritional deficiencies and support the body's increased energy needs.
Correct Answer is D
Explanation
Choice A Reason:
Age 45 years is incorrect.While age is a significant factor in osteoporosis risk, 45 years old isn't inherently considered a high-risk age for developing osteoporosis. However, bone density tends to decrease gradually with age, and after menopause in women, there's a more significant decline due to hormonal changes.
Choice B Reason:
Regular aerobic exercise is incorrect. Regular exercise, particularly weight-bearing and muscle-strengthening activities, is typically beneficial for bone health. It can help maintain or improve bone density and strength, reducing the risk of osteoporosis. Therefore, regular aerobic exercise is generally considered a protective factor against osteoporosis, rather than a risk factor.
Choice C Reason:
Uses NSAIDs for pain relief is incorrect. While long-term use of certain medications, such as glucocorticoids (steroids), can increase the risk of osteoporosis due to their impact on bone density, the use of NSAIDs (nonsteroidal anti-inflammatory drugs) for pain relief isn't directly linked to osteoporosis as a significant risk factor. However, chronic use of certain medications might have implications for bone health and should be assessed on an individual basis.
Choice D Reason:
Smoking is a known risk factor for osteoporosis. It can have detrimental effects on bone health by interfering with the body's ability to absorb calcium, decreasing estrogen levels, and impairing bone-forming cells. Consequently, smokers have a higher risk of developing osteoporosis compared to non-smokers.
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