Following a fractured left tibia, which necessitated placement of long leg cast, a client is using crutches to ambulate. During an orthopedic follow-up visit, a client reports to the nurse having difficulty managing the crutches. Which assessment should the nurse perform?

Measure capillary refill time.

Palpate for dependent edema.

Determine degree of skin elasticity.

Note hand and forearm strength.

Answer and Explanation

The Correct Answer is D

A.   Capillary refill time assessment is more relevant for circulatory status and would not directly address the client's difficulty with crutch management.
B.   Palpating for dependent edema would not provide information directly related to the client's ability to use crutches.

C.   Assessing skin elasticity is not directly related to the client's ability to manage crutches.
D.   Strength in the hands and forearms is essential for proper crutch use, as these muscles bear much of the weight while ambulating with crutches.

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Correct Answer is A

Explanation

A. Hypoparathyroidism can lead to hypocalcemia, which increases the risk of tetany and seizures, making the risk for injury the highest priority.
B. Deficient knowledge is important to address but is secondary to immediate physiological risks.
C. Anxiety may be present but is not as critical as the risk for injury due to hypocalcemia.
D. Imbalanced nutrition should be managed but is not the immediate priority compared to the risk for injury.

A. Encourage sitting up and ambulation B. Monitor for bleeding once daily C. Use Incentive spirometer every 1 hour D. Promote adequate hydration E. Assess for sedation after pain medications F. Complete neurologic assessment every 2 hours G. Administer pain medication after activity

Correct Answer is ["A","C","D","E","G"]

Explanation

A. Early ambulation helps prevent complications such as atelectasis, pneumonia, and deep vein thrombosis (DVT). It also promotes intestinal motility.
B. Monitoring for bleeding should be more frequent, especially in the immediate postoperative period, rather than just once daily.
C. This helps prevent respiratory complications such as atelectasis and promotes lung expansion.
D. Adequate hydration is essential to maintain fluid balance, promote healing, and prevent complications such as urinary tract infections and constipation.
E. Monitoring for sedation is crucial to ensure that pain medications are not causing excessive drowsiness, which could impair the client's ability to participate in activities such as ambulation and use of the incentive spirometer.

F. While assessing neurological status is important, frequent neurological assessments are more relevant for clients with neurological conditions or concerns. In this case, routine assessments should be sufficient unless the client has specific neurological symptoms.
G. Pain medications should be administered prophylactically before activity. However, it can also be administered after activity in case the client complains of pain.

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Following a fractured left tibia, which necessitated placement of long leg cast, a client is using crutches to ambulate. During an orthopedic follow-up visit, a client reports to the nurse having difficulty managing the crutches. Which assessment should the nurse perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which is the priority nursing problem for a client with hypoparathyroidism?

Correct Answer is A

Explanation

Patient Data Exhibits Click to select the 5 most important nursing interventions for postoperative client care.

Correct Answer is ["A","C","D","E","G"]

Explanation

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