An older adult client fell while getting out of bed. Which assessment finding indicates a possible hip fracture?
The client cries out when the nurse attempts to examine him.
The client is extremely confused and trying to get up.
The skin of one leg is cooler than that of the upper extremities,
One leg is shorter than the other and has a protruding bump on the side.
The Correct Answer is D
This finding suggests that the client may have experienced a hip fracture. The shorter leg can be a result of the fractured bone, causing a misalignment or displacement. The protruding bump on the side can be a sign of a dislocated or fractured hip joint. It is important to assess and confirm this suspicion through appropriate diagnostic measures, such as X-rays, to provide the necessary medical intervention and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Nausea and vomiting can lead to excessive loss of fluids and electrolytes, including potassium, from the body. Gastroenteritis is an inflammation of the gastrointestinal tract typically caused by viral or bacterial infections. It is commonly characterized by symptoms such as diarrhea, vomiting, abdominal pain, and fever. Antibiotics are not typically used to treat viral gastroenteritis and would not directly cause the electrolyte imbalance. Administration of IV Furosemide, a diuretic, would increase urine output but is not typically used to treat gastroenteritis. The fever itself may contribute to fluid loss but would not directly cause the electrolyte imbalance.
Correct Answer is D
Explanation
The nurse should inform the client that a common side effect of Lisinopril, an ACE inhibitor, is a chronic dry cough. ACE inhibitors can cause irritation in the respiratory tract, leading to a persistent cough. It is important for the client to be aware of this side effect and report it to their healthcare provider if it becomes bothersome.
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