A nurse is performing a neurovascular assessment on a client who has a fractured left femur. For which of the following findings should the nurse intervene immediately?

Left leg is warm to the touch.

Left pedal pulse strength is 2.

The client reports pain in the foot of the left leg.

Capillary refill in the left foot is 3 seconds.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
A warm left leg is a normal finding and does not require immediate intervention. Warmth indicates adequate circulation to the limb.
Choice B rationale:
A pedal pulse strength of 2 in the left leg indicates diminished pulse but does not require immediate intervention. The nurse should continue to monitor the pulse and report any significant changes to the healthcare provider.
Choice C rationale:
The client's report of pain in the foot of the left leg is an expected finding due to the fractured left femur. Pain is a subjective symptom, and the nurse should address the client's pain appropriately but not intervene immediately based on this finding.
Choice D rationale:
This is the correct choice. A capillary refill time of 3 seconds in the left foot suggests impaired circulation, which could be indicative of compartment syndrome or other circulation-related issues. The nurse should intervene immediately by notifying the healthcare provider to prevent further complications.

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Correct Answer is B

Explanation

Choice A rationale:

A defined area of cool, boggy skin is not indicative of a stage 2 pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss, usually appearing as a shallow open ulcer with a red-pink wound bed, without slough or bruising.

Choice B rationale:

A shallow crater involving the epidermis is characteristic of a stage 2 pressure injury. It presents as a partial-thickness skin loss with the loss of the epidermis, and the wound may be superficial and appear as an abrasion, blister, or shallow ulcer.

Choice C rationale:

The reddened area that does not blanch is more indicative of an early-stage pressure injury (Stage 1). In Stage 1, the skin remains intact, but there is non-blanch-able erythema indicating damage to the skin and underlying tissue.

Choice D rationale:

Undermining or tunneling of the skin is not specific to stage 2 pressure injuries. These features may be observed in more advanced stages of pressure injuries, such as stages 3 and 4, where there is full-thickness skin loss with damage to the subcutaneous tissue and underlying structures.

A. Increase high-impact activities. B. Consume a low-protein diet. C. Maintain a BMI of 30 to 35. D. Include fiber in the diet.

Correct Answer is D

Explanation

Choice A rationale:

The nurse should not instruct the older adult client with osteoporosis to increase high-impact activities. Osteoporosis is a condition characterized by decreased bone density and strength, making high-impact activities potentially harmful as they could increase the risk of fractures.

Choice B rationale:

The nurse should not advise the client to consume a low-protein diet. Adequate protein intake is essential for maintaining muscle mass and overall musculoskeletal health, especially in older adults who may be at risk of muscle wasting.

Choice C rationale:

The nurse should not encourage the client to maintain a BMI of 30 to 35. A BMI within this range is considered obese and can put additional stress on the musculoskeletal system, increasing the risk of joint problems and other health issues.

Choice D rationale:

Including fiber in the diet is a correct instruction for promoting musculoskeletal health. Fiber-rich foods can help maintain bowel regularity and prevent constipation, which is important for overall comfort and mobility in older adults with osteoporosis.

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A nurse is performing a neurovascular assessment on a client who has a fractured left femur. For which of the following findings should the nurse intervene immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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