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 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.

A. Instruct the client to avoid foods with gluten, such as wheat bread. B. Explain that the need to restrict fluids is the primary limitation. C. Advise the client to limit foods that are high in calcium and iron. D. Describe the use of an elimination diet to find trigger foods

Correct Answer is D

Explanation

A. Instruct the client to avoid foods with gluten, such as wheat bread.
While some individuals with Crohn's disease may experience improvement by avoiding certain types of carbohydrates, including gluten, this recommendation is not universally applicable to all individuals with Crohn's disease. Gluten restriction is more relevant for those with gluten sensitivity or celiac disease.

B. Explain that the need to restrict fluids is the primary limitation.
This statement is not accurate. Fluid restriction is not a primary dietary limitation for individuals with Crohn's disease. In fact, maintaining adequate hydration is generally important for overall health. Restricting fluids is not a standard dietary recommendation for managing Crohn's disease.

C. Advise the client to limit foods that are high in calcium and iron.
Limiting foods high in calcium and iron is not a standard recommendation for Crohn's disease. In fact, adequate intake of essential nutrients, including calcium and iron, is important for overall health. Limiting these nutrients could lead to nutritional deficiencies.

D. Describe the use of an elimination diet to find trigger foods.
This is the most appropriate response. Crohn's disease symptoms can vary among individuals, and identifying trigger foods through an elimination diet can help personalize dietary recommendations. By systematically eliminating and reintroducing foods, individuals can identify which specific foods may exacerbate their symptoms.

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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

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

Correct Answer is B

Explanation

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

Correct Answer is D

Explanation

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