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 ["C","D"]

Explanation

Based on the client’s current condition and the urgency of the interventions, the nurse should complete the following prescriptions first:

C) Apply oxygen 1 L/minute: The client’s oxygen saturation level needs to be kept above 94%. Given her difficulty in breathing and the fact that she is pale and sitting upright, it’s crucial to ensure she is receiving enough oxygen.
D) Give albuterol as ordered: Albuterol is a bronchodilator that can help relieve the client’s asthma symptoms. Since her symptoms did not resolve after taking her usual dose of albuterol, administering another dose as ordered can help improve her breathing.

A. Decreased range of motion B. Pain with movement C. Reduced strength in left upper extremity D. Reduced pulse distal to injury E. Coolness of the skin

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

Choice A rationale

Decreased range of motion is generally associated with a rotator cuff injury. This is because the rotator cuff is a group of muscles and tendons that surround the shoulder joint, keeping the head of the upper arm bone firmly within the shallow socket of the shoulder. When these muscles or tendons are injured, it can limit the shoulder’s range of motion.

Choice B rationale

Pain with movement can be a symptom of both a rotator cuff injury and a humeral fracture. Both conditions involve structures that are integral to the movement of the arm, and damage to these structures can cause pain when they are moved or put under strain.

Choice C rationale

Reduced strength in the left upper extremity is more commonly associated with a rotator cuff injury. The rotator cuff is responsible for the stability of the shoulder joint and enables the arm to lift and rotate. An injury to the rotator cuff can therefore lead to a reduction in the strength of the arm.

Choice D rationale

Reduced pulse distal to the injury is more commonly associated with a humeral fracture. This is because a fracture to the humerus could potentially damage the blood vessels running along the bone, leading to a reduced pulse further down the arm.

Choice E rationale

Coolness of the skin is more commonly associated with a humeral fracture. This could be due to damage to the blood vessels, leading to reduced blood flow and therefore a lower skin temperature.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?

Correct Answer is ["C","D"]

Explanation

The same 68-year-old male patient from the previous as been assessed. For each of the following findings, indicate whether they are generally associated with a rotator cuff injury or a humeral fracture.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

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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?