A nurse is establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client's right leg should be of the most concern to the nurse?
The client's foot feels cooler than in the previous assessment.
The client's pedal pulse in the right foot is not palpable.
The client's capillary refill time is 5 seconds in the toes.
The client reports a pain level of 8 on a scale from 0 to 10.
The Correct Answer is B
The most concerning finding in the assessment of a client's right leg after a femoropopliteal bypass graft would be if the client's pedal pulse in the right foot is not palpable. This could indicate a problem with blood flow to the limb.
The other options are also concerning and should be reported to the healthcare provider.
a) A cooler foot may indicate decreased blood flow to the limb.
c) A capillary refill time of 5 seconds may also indicate decreased blood flow.
d) A pain level of 8 on a scale from 0 to 10 should also be reported and addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Echolalia is the repetition of words or phrases spoken by others. In this case, the client is repeating the nurse's question, "How are you?" This is an example of echolalia.
a) "I am lovistrated" is an example of neologism, which is the creation of new words.
b) "Super, trooper, and duper" is an example of clang association, which is the use of words that sound alike but have no logical connection.
d) "Pink spots in Africa" is an example of a thought disorder, which is a disruption in the organization and expression of thoughts.
Correct Answer is C
Explanation
MDMA, commonly known as ecstasy or Molly, is a stimulant drug that affects the central nervous system. It primarily acts on serotonin, dopamine, and norepinephrine neurotransmitters. The use of MDMA can lead to altered perception, increased sensory awareness, and hallucinations. Hallucinations may involve visual, auditory, or tactile sensations that are not based on reality.
The other findings mentioned—hypothermia (abnormally low body temperature), somnolence (excessive sleepiness), and muscle weakness—are not typically associated with MDMA use. Instead, MDMA use may lead to increased body temperature (hyperthermia), increased energy levels, agitation, increased heart rate, and muscle tension.
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