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A nurse performing a head to toe neurovascular check on a patient in a long leg cast notes an indication of altered perfusion as evidenced by:

warm feet and hands.

numbness of distal limb.

palpable peripheral pulses.

capillary refill of 3 seconds.

Answer and Explanation

The Correct Answer is B

A. Warm feet and hands.

Warmth suggests good blood flow and is a normal finding.

B. Numbness of distal limb.

Numbness is a sign of neurovascular compromise, possibly from swelling or impaired circulation due to the cast.

C. Palpable peripheral pulses.

Pulses are a positive finding indicating adequate perfusion.

D. Capillary refill of 3 seconds.

Capillary refill less than or equal to 3 seconds is considered normal.

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Correct Answer is B

Explanation

A. Move body parts rapidly through the movements.

Rapid movement can cause injury and discomfort. Movements should be slow and smooth.

B. Support extremities above and below joints.

Supporting both above and below the joint ensures joint stability and prevents strain or injury during passive ROM.

C. Stretch the body part just beyond the existing range of motion.

Passive ROM should stay within the current range. Forcing motion can cause pain or injury.

D. Continue moving body parts if muscle spasticity occurs.

If spasticity occurs, movement should stop. Forcing motion through spasms can increase injury risk.

A. Hold the crutches on your unaffected side when preparing to sit in a chair B. Hold the crutches 9 inches in front and to the side of each foot C. Lean on the crutches to support your body weight when standing D. Fully extend your arms when holding onto the hand grips

Correct Answer is A

Explanation

A. Hold the crutches on your unaffected side when preparing to sit in a chair

This helps maintain balance and control while transitioning from standing to sitting.

B. Hold the crutches 9 inches in front and to the side of each foot

The correct placement is approximately 6 inches (not 9) in front and 6 inches to the side of each foot for stability.

C. Lean on the crutches to support your body weight when standing

Weight should be supported by the hands on the handgrips, not the axillae, to avoid nerve injury (e.g., brachial plexus damage).

D. Fully extend your arms when holding onto the hand grips

The elbows should be slightly flexed (about 20-30 degrees) to allow proper support and shock absorption.

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A nurse performing a head to toe neurovascular check on a patient in a long leg cast notes an indication of altered perfusion as evidenced by:

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