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 A
Explanation
The patient's vital signs indicate signs of septic shock, including low blood pressure (70/46 mm Hg), tachycardia (136 beats/min), and tachypnea (32 breaths/min). The patient also has a high temperature of 104°F, indicating a fever. These findings suggest a systemic response to an infection that is leading to inadequate tissue perfusion.The initial treatment for septic shock includes fluid resuscitation to improve blood pressure and tissue perfusion. A fluid bolus of 0.9% Sodium Chloride (normal saline) is commonly used to restore intravascular volume in septic shock. It helps to increase blood pressure, improve organ perfusion, and stabilize the patient's condition.
The other interventions, such as administering Pantoprazole (Protonix) for gastrointestinal protection, giving Acetaminophen (Tylenol) for fever control, or administering rapid-acting insulin per sliding scale for hyperglycemia, are important aspects of care but should be implemented after the initial fluid resuscitation. The priority at this moment is to address the patient's hypotension and inadequate tissue perfusion through the administration of fluid bolus.
Correct Answer is A
Explanation
In a client with minimal change nephrotic syndrome (MCNS), the primary concern is the management of fluid volume and hydration status. MCNS is characterized by increased glomerular permeability, leading to excessive protein loss in the urine and subsequent hypoalbuminemia. This can result in fluid retention and edema formation, including facial edema.
Hypertension is a common complication in clients with MCNS, and it further contributes to fluid retention and potential complications. Therefore, closely monitoring the client's fluid volume and hydration status, including daily weights, intake and output measurements, and assessment of edema, is crucial to detect any changes and guide appropriate interventions.
While other actions, such as consulting with a registered dietitian about adequate intake or using sterile technique to prevent infections, may be important aspects of the client's care, they are not the priority in this situation. The immediate concern is managing the client's hypertension and fluid volume status to prevent complications associated with MCNS.
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