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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Remind the client to practice pelvic floor (Kegel) exercises regularly.
Pelvic floor exercises, such as Kegel exercises, are typically recommended for conditions involving weakened pelvic floor muscles. However, in the context of urinary retention related to sensorimotor deficits in multiple sclerosis, the issue is more neurological in nature. Therefore, pelvic floor exercises may not address the underlying problem effectively.

B. Provide a bedside commode for immediate use in the client's room.
While a bedside commode may be beneficial for individuals with mobility issues, it doesn't directly address the problem of urinary retention. It focuses on providing a convenient means for the client to void when needed, but it doesn't address the inability to empty the bladder spontaneously.

C. Explain the need to limit intake of oral fluids to reduce client discomfort.
Limiting oral fluids is not an appropriate intervention for urinary retention. In fact, it could lead to dehydration, which is not a recommended approach. The focus should be on addressing the difficulty in voiding through appropriate techniques.

D. Teach the client techniques for performing intermittent catheterization.
This is the correct choice. Intermittent catheterization is a direct and effective method to manage urinary retention in clients with sensorimotor deficits. Teaching the client how to perform intermittent catheterization empowers them to maintain regular bladder emptying and prevent complications associated with urinary retention.

A. Jugular vein distention. B. Carotid bruit. C. Nuchal rigidity. D. Palpable cervical lymph node.

Correct Answer is B

Explanation

A. Jugular vein distention:
Jugular vein distention is not typically associated with an increased risk of a stroke. It may be indicative of issues related to cardiac or fluid volume status.

B. Carotid bruit:
This is the correct answer. A carotid bruit, an abnormal sound caused by turbulent blood flow through the carotid artery, may indicate the presence of atherosclerosis and increased risk of stroke. It suggests a narrowing or blockage in the carotid artery, which can potentially lead to emboli and subsequent stroke.

C. Nuchal rigidity:
Nuchal rigidity, stiffness of the neck, is associated with conditions such as meningitis but is not a direct risk factor for a stroke.

D. Palpable cervical lymph node:
Palpable cervical lymph nodes may be indicative of infection or inflammation in the head and neck region but are not directly associated with an increased risk of a stroke.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?

Correct Answer is D

Explanation

The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?

Correct Answer is B

Explanation

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