An elderly patient who had a fall at a store is admitted with a potential right hip fracture.
What assessment finding should the nurse report to the healthcare provider?

The left lower extremity is warm to touch.

Bilateral pedal pulses are present and strong.

The patient wiggles their right toes when the sole of the right foot is tickled.

The right leg is externally rotated and shorter than the left.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While it’s important to assess all aspects of the patient’s condition, a warm left lower extremity does not necessarily indicate a right hip fracture. It could be related to other conditions, such as deep vein thrombosis or cellulitis.

Choice B rationale

The presence of strong bilateral pedal pulses is a positive sign and does not indicate a hip fracture. It suggests that the patient has good peripheral circulation.

Choice C rationale

The ability to wiggle the toes when the sole of the right foot is tickled does not necessarily indicate a hip fracture. This is a normal response and suggests that the patient has intact sensory and motor function in the foot.

Choice D rationale

A right leg that is externally rotated and shorter than the left is a classic sign of a hip fracture. This occurs because the fracture can cause the femoral head to tilt and rotate outward, making the leg appear shorter.

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Correct Answer is A

Explanation

Choice A rationale

Osteoarthritis is a joint disease in which the tissues in the joint, including the cartilage, break down over time. The degradation of joint cartilage is the primary pathological condition that leads to the symptoms of osteoarthritis, such as increased pain and stiffness.

Choice B rationale

A systemic inflammatory response is not the primary cause of osteoarthritis. While inflammation can occur in the affected joint, osteoarthritis is not a systemic inflammatory disease like rheumatoid arthritis.

Choice C rationale

An infectious process in the synovial fluid is not typically associated with osteoarthritis. Infections can lead to a different type of arthritis known as septic arthritis.

Choice D rationale

A decrease in bone mineral density is associated with osteoporosis, not osteoarthritis. In osteoarthritis, the issue is primarily with the degradation of cartilage, not a loss of bone density.

A. Supervisor of the neurology unit. B. Nurse in charge of risk management. C. Nurse case manager. D. Adult nurse practitioner.

Correct Answer is C

Explanation

Choice A rationale

While the supervisor of the neurology unit may have expertise in neurology, they are not typically responsible for coordinating the progression of a patient’s care following a spinal cord injury.

Choice B rationale

The nurse in charge of risk management is typically responsible for identifying and evaluating risks in the healthcare setting. They are not typically involved in the direct management of a patient’s care.

Choice C rationale

The nurse case manager is specifically trained to coordinate and manage the care of patients with complex conditions, including spinal cord injuries. They work with the patient, family, and healthcare team to develop a comprehensive care plan.

Choice D rationale

While an adult nurse practitioner can provide a high level of care, they are not typically responsible for managing the progression of a patient’s care following a spinal cord injury.

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An elderly patient who had a fall at a store is admitted with a potential right hip fracture.What assessment finding should the nurse report to the healthcare provider?

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An elderly patient who had a fall at a store is admitted with a potential right hip fracture.
What assessment finding should the nurse report to the healthcare provider?