After falling down the basement steps, a client is brought to the emergency room. X-rays confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?
Increased temperature to lower extremity.
Right foot pale with sluggish capillary refill.
Circumferential edema of right foot.
Complaint of throbbing right leg pain
The Correct Answer is B
A. Increased temperature to the lower extremity:
While increased temperature could indicate inflammation or infection, it is not as immediately concerning as impaired circulation.
B. Right foot pale with sluggish capillary refill.
This finding suggests a potential impairment in blood flow to the right foot, which could be due to complications such as compartment syndrome or impaired circulation. Compartment syndrome is a serious condition that occurs when there is increased pressure within a muscle compartment, leading to reduced blood flow. Pale color and sluggish capillary refill indicate compromised circulation and require prompt intervention to prevent further damage.
C. Circumferential edema of the right foot:
Edema is a common finding after a fracture and cast application. However, in the context of pale color and sluggish capillary refill, it may indicate increased pressure within the compartment, requiring immediate attention.
D. Complaint of throbbing right leg pain:
Pain is a common complaint after a fracture, and throbbing pain may be expected. However, the priority is to address the potential compromise in circulation indicated by the pale color and sluggish capillary refill.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Jogs more frequently than usual daily routine:
Exercise, including jogging, is generally not associated with an increased risk of renal calculi. In fact, regular physical activity can have health benefits.
B. Eats a vegetarian diet with cheese 2 to 3 times a day:
A vegetarian diet alone is not necessarily a risk factor for renal calculi. However, the inclusion of high-oxalate foods, such as certain types of cheese, may contribute to the formation of kidney stones.
C. Experiences additional stress since adopting a child:
Stress is not a direct risk factor for renal calculi. However, certain dietary and lifestyle factors play a more significant role in stone formation.
D. Drinks several bottles of carbonated water daily:
This is the correct answer. Consuming large amounts of carbonated water, especially if it is high in phosphoric acid, can contribute to the formation of kidney stones. Carbonated beverages may increase the excretion of calcium in the urine, potentially leading to stone formation.
Correct Answer is B
Explanation
A. Return appointments will be needed for IV medication:
This statement does not address the specific concern related to pain management in Raynaud's disease, and routine IV medication may not be the primary approach for pain relief in this condition.
B. Wearing gloves when handling cold items guards against painful spasms:
This is the correct answer. Raynaud's disease is characterized by vasospasm of small arteries, often triggered by exposure to cold or stress. Wearing gloves helps to minimize exposure to cold and can prevent painful spasms associated with Raynaud's.
C. Enrolling in a pain clinic can provide pain relief alternatives:
While pain clinics can offer various pain management strategies, the specific recommendation for Raynaud's disease involves minimizing exposure to cold and stress rather than enrolling in a pain clinic.
D. Painful areas should be rubbed gently until the pain subsides:
Rubbing painful areas may not be recommended, as it can potentially aggravate vasospasm in individuals with Raynaud's disease. The emphasis is on preventing triggers like cold exposure.
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