A nurse is collecting data from a client who has a long leg cast that was applied 2 days ago. Which of the following findings should the nurse report to the provider?

Client reports increasing pain in the affected extremity.

Client reports itching beneath the cast.

Client's toes of the affected extremity feel warm to the touch.

Client has a capillary refill of 3 seconds in the toes of the affected extremity.

Answer and Explanation

The Correct Answer is A

A long leg cast is used to immobilize fractures and promote bone healing, but it can also lead to complications such as compartment syndrome, impaired circulation, and nerve compression. After cast application, ongoing assessment of neurovascular status is essential to detect early signs of compromised perfusion. Pain that worsens rather than improves is a critical warning sign of potential complications requiring immediate intervention. Nurses must differentiate expected discomfort from abnormal findings that indicate tissue ischemia.

Rationale:
A. Increasing pain in the affected extremity is a hallmark early sign of compartment syndrome or impaired circulation under the cast. This type of pain is often severe, unrelieved by analgesics, and may worsen with movement. It indicates rising pressure within the muscle compartments that can compromise blood flow and tissue viability, requiring immediate provider notification.

B. Itching beneath the cast is a common and expected finding during the healing process. It results from skin dryness and tissue regeneration under immobilization. Although uncomfortable, it does not indicate neurovascular compromise and can be managed with safe comfort measures.

C. Warm toes indicate adequate peripheral perfusion and are a normal finding after cast application. This suggests that arterial blood flow to the distal extremity is intact. It is a reassuring sign rather than an abnormal one that requires reporting.

D. Capillary refill of 3 seconds is slightly delayed but may still be within acceptable limits depending on baseline and clinical context. However, it is less urgent than escalating pain. It should be monitored closely, but increasing pain is a more critical early indicator of compromised circulation that requires immediate attention.

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Correct Answer is B

Explanation

Home safety is a critical component of care for clients who have had a Cerebrovascular accident because they often experience weakness, impaired balance, visual deficits, and decreased coordination. These limitations increase the risk of falls and injuries in the home environment. The nurse’s role is to identify and correct hazards that could contribute to accidents while promoting independence and safety. Environmental modifications are key to reducing preventable harm.

Rationale:
A. Setting the water heater to 54.4°C (130°F) is unsafe because it increases the risk of thermal injury or burns, especially in clients with sensory or mobility impairments. The recommended safe setting is typically lower (around 49°C/120°F) to prevent scalding injuries. This does not promote safety.

B. Replacing burned-out light bulbs is an appropriate safety intervention because adequate lighting reduces the risk of falls and improves mobility in clients with neurological deficits. Good visibility is essential for clients recovering from stroke who may have impaired balance, coordination, or visual field deficits. This directly enhances environmental safety.

C. Running extension cords under throw rugs is unsafe because it creates a tripping hazard and increases the risk of falls. Additionally, covering cords can lead to overheating and potential fire hazards. This practice should be avoided in home safety planning.

D. Ensuring the client wears soft-soled slippers may improve comfort but does not provide optimal safety if the footwear lacks proper support or traction. In stroke clients, supportive, non-slip footwear is recommended to reduce fall risk. Soft slippers may actually increase instability if they do not fit securely.

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"E"}

Explanation

The client presents with severe hypertension, proteinuria, hyperreflexia, edema, and elevated liver enzymes, all consistent with worsening preeclampsia with risk for end-organ involvement. Severe preeclampsia can rapidly progress to eclampsia (seizures) and placental abruption due to poor placental perfusion and vascular instability. Early recognition of these complications is critical for maternal and fetal safety.

Rationale for correct choices:

• Seizures are the defining feature of eclampsia, which is a severe complication of preeclampsia. The client already demonstrates severe hypertension, hyperreflexia (4+ reflexes), and proteinuria, indicating significant central nervous system irritability. These findings increase the risk of cerebral edema and seizure activity. Without prompt management, preeclampsia can progress to eclampsia, which is life-threatening for both mother and fetus.

• Placental abruption is a serious complication of preeclampsia caused by vasospasm and impaired placental perfusion leading to premature separation of the placenta from the uterine wall. Severe hypertension and endothelial damage increase this risk. Although fetal status is currently stable, the underlying vascular instability places the client at high risk. Abruptions can lead to fetal distress, hemorrhage, and maternal instability.

Rationale for incorrect choices:

• Cervical insufficiency is a structural problem of the cervix that leads to painless cervical dilation and preterm birth, typically unrelated to hypertensive disorders of pregnancy. This client’s condition is driven by vascular and systemic endothelial dysfunction rather than cervical weakness. There ae no cervical changes or painless dilation in the assessment. Therefore, it is not a likely complication.

• Although preeclampsia can cause fluid shifts and increased vascular resistance, this client does not show clinical signs of cardiac failure such as pulmonary edema, crackles, or decreased oxygenation. Oxygen saturation is normal, and lung sounds are normal. Although edema is present, it is more consistent with preeclampsia-related fluid retention.

• Hypoglycemia is not associated with preeclampsia or hypertensive disorders of pregnancy. The client’s blood glucose is within normal limits, and there is no evidence of insulin use or fasting state contributing to low blood sugar. The symptoms and laboratory findings are unrelated to glucose metabolism. Therefore, hypoglycemia is not a relevant complication.

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A nurse is collecting data from a client who has a long leg cast that was applied 2 days ago. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is completing a home safety visit for a client who had a cerebrovascular accident (CVA). Which of the following actions should the nurse take?

Correct Answer is B

Explanation

The nurse is continuing to assist with the care of the client. Drag words from the choices below to fill in each blank in the following sentence. The complications that the client is at greatest risk for developing are dropdownanddropdown.

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"E"}

Explanation

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