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.
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Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Respirations: Morphine is an opioid analgesic that can cause respiratory depression, so monitoring the client's respiratory status is crucial after administration.
Ice application to the shoulder: Applying ice can help reduce swelling and inflammation in the injured area. This is important for managing pain and preventing further complications, such as excessive swelling or damage to surrounding tissues.
Correct Answer is A
Explanation
A. Nitroglycerin should be withheld because it can cause severe hypotension when administered to a client who has recently taken sildenafil, which also causes vasodilation.
B. Aspirin is generally safe to administer and can help with chest pain, especially if a myocardial infarction is suspected.
C. Heparin is an anticoagulant used for treating various conditions and is not contraindicated in this scenario.
D. Morphine can be administered to manage severe chest pain, as it is not contraindicated in this situation.
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