An older adult client who fell at the store is admitted with a possible fracture of the right hip. Which assessment finding should the nurse report to the healthcare provider?
Right leg externally rotated and shorter than left.
Wiggles right foes when sole of right foot is tickled.
Left lower extremity is warm to touch.
Bilateral pedal pulses present and strong.
The Correct Answer is A
A. The right leg being externally rotated and shorter than the left is a classic sign of a hip fracture and should be reported for further evaluation and management.
B. The ability to wiggle the right toes indicates that some nerve function is intact and is not a concerning finding in this context.
C. A warm left lower extremity could indicate circulation but is not as urgent as a potential fracture finding.
D. Strong bilateral pedal pulses are a positive sign, suggesting adequate blood flow, and do not require immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Horrible Thoughts and Memories: The client expresses having "horrible thoughts and memories" about the house collapsing, which indicates the possibility of acute stress reactions or post-traumatic stress disorder (PTSD). This mental health concern needs immediate attention to ensure the client's psychological well-being.
Difficulty Falling Asleep: The client's difficulty falling asleep due to intrusive thoughts is concerning. Sleep is crucial for recovery, and ongoing sleep disturbances can exacerbate mental health issues and impede healing. Addressing her need for sleep medications or alternative interventions should be prioritized.
Emotional State: The client states, "I used to be so happy before all of this happened. Now I can't seem to get out of this funk I am in," indicating possible depression or an adjustment disorder. This emotional state warrants evaluation and support from a mental health professional.
Request for Quieter Area: The client requests a quieter area of the unit due to the noise from the nurses' station. While this may not be as urgent as the mental health concerns, accommodating her request can significantly improve her comfort and ability to rest
Correct Answer is B
Explanation
A. Continue to provide life support until a thorough search for a guardian is completed: While continuing life support is essential, the delay involved in waiting for a guardian to be located could jeopardize the patient's life. Immediate surgery is necessary to save the client, and life support is unlikely to be sufficient on its own.
B. Carry on with surgical preparation of the client without a signed informed consent: In cases of medical emergencies where the patient is unable to provide consent (such as being unresponsive), the healthcare team can proceed with necessary life-saving procedures without waiting for formal written consent. The principle of implied consent applies in this scenario, where it is assumed the patient would consent to life-saving treatment if they were able to do so.
C. Ask the client's friend to sign the informed consent since the client is unresponsive: The friend does not have the legal authority to provide informed consent unless they are a legal guardian or have been granted specific decision-making powers. Consent should not be obtained from a non-guardian in this situation.
D. Notify the unit manager that an emergency court order is needed to allow surgery: While emergency court orders can sometimes be used in certain legal situations, they are unnecessary when the immediate need for life-saving surgery overrides the formalities of obtaining a signed consent. The focus should be on proceeding with treatment to preserve life.
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