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
Explanation
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.
Correct Answer is B
Explanation
A. While the fall at home provides background information, it is not the immediate concern for the healthcare provider regarding the current change in the client's status.
B. The increasing confusion of the client is the most critical and urgent information that should be communicated first, as it indicates a potential change in the client's neurological status.
C. The client's healthcare power of attorney is important but not relevant to the immediate medical situation.
D. While understanding the currently prescribed medications is useful, it does not take precedence over addressing the client's acute change in mental status.
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