A nurse is planning care for a client who has a radial fracture and a newly placed short arm cast on the left arm. Which of the following findings is the nurse's priority?

The client requires assistance with getting dressed.

The client reports numbness of the fingers of the left hand.

The client reports itching of the left arm.

The client has a pillow under their left arm.

Answer and Explanation

The Correct Answer is B

Choice A reason: While requiring assistance with getting dressed is an important consideration in care planning, it is not the most immediate priority. The nurse should ensure that the client's basic needs are met, but this does not represent an acute medical concern.

Choice B reason: The client reporting numbness of the fingers of the left hand is the most urgent priority. Numbness can indicate neurovascular compromise or increased pressure within the cast, which could lead to further injury or complications such as compartment syndrome. Immediate assessment and intervention are required to prevent permanent damage.

Choice C reason: Itching of the left arm under the cast is a common complaint and can be uncomfortable for the client. However, it is not a priority over potential neurovascular compromise. The nurse can provide education on how to safely alleviate itching without compromising the integrity of the cast.

Choice D reason: Having a pillow under the left arm is part of proper positioning to reduce swelling and provide comfort. While it is a part of good nursing care, it is not a priority over signs of neurovascular compromise.

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Correct Answer is C

Explanation

Choice A reason: Epithelialization at the site of a major full-thickness burn would not be expected 12 hours post-injury. Epithelialization is a later stage of wound healing where new skin cells form and cover the wound. In full-thickness burns, this process is significantly delayed and typically requires skin grafting for wound closure.

Choice B reason: Severe pain is not typically associated with full-thickness burns due to the destruction of nerve endings in the skin. However, there may be severe pain in the surrounding areas that have sustained less severe burns.

Choice C reason: Edema is a common and expected finding at the site of a major full-thickness burn 12 hours post-injury. The inflammatory response to the burn injury leads to increased vascular permeability and fluid shift from the intravascular to the interstitial space, resulting in edema.

Choice D reason: Blistering is characteristic of partial-thickness burns (second-degree burns) but not full-thickness burns (third-degree burns). In full-thickness burns, the skin is destroyed to the point where blisters do not form.

A. Constipation B. Decreased tear production C. Mouth ulcers D. Peripheral neuropathy

Correct Answer is C

Explanation

Choice A reason: Constipation can be a side effect of many cancer treatments, including radiation therapy. However, it is not commonly associated with targeted radiation therapy to the neck. Constipation is more often related to opioid pain medications, decreased physical activity, or dietary changes that a patient may experience during cancer treatment.

Choice B reason: Decreased tear production is not a typical side effect of targeted radiation therapy to the neck. This condition, known as dry eye syndrome, is more commonly associated with radiation therapy that affects the eye or orbital area directly.

Choice C reason: Mouth ulcers, also known as mucositis, are a common adverse effect of radiation therapy to the neck. Radiation can damage the mucosal lining of the mouth, leading to painful sores that can affect a patient's ability to eat, speak, and swallow. These ulcers typically develop one to two weeks after starting treatment and may persist for some time after the treatment ends.

Choice D reason: Peripheral neuropathy, which involves damage to the peripheral nerves and often results in symptoms like numbness, tingling, or pain in the hands and feet, is not a common side effect of radiation therapy to the neck. It is more frequently associated with certain chemotherapeutic agents or radiation therapy to areas of the body where peripheral nerves are located.

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A nurse is planning care for a client who has a radial fracture and a newly placed short arm cast on the left arm. Which of the following findings is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

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