Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client’s right radial pulse. Which action should the nurse take first?
Elevate the client’s right hand on one or two pillows.
Measure the client’s blood pressure and apical heart rate.
Complete a neurovascular assessment of the right hand.
Notify the healthcare provider quickly.
The Correct Answer is C
Choice A reason: Elevating the hand reduces edema, potentially improving circulation, but is premature without assessing the absent radial pulse’s cause. Post-fracture, compartment syndrome or arterial injury risks ischemia. Neurovascular assessment identifies severity, guiding targeted interventions to restore perfusion, making elevation secondary to assessment.
Choice B reason: Measuring blood pressure and heart rate provides systemic data but not localized insight into the absent radial pulse, likely from arterial compression post-surgery. Neurovascular assessment evaluates limb perfusion, detecting compartment syndrome or occlusion, critical for urgent intervention to prevent tissue necrosis.
Choice C reason: Completing a neurovascular assessment evaluates pulse, color, warmth, sensation, and movement. Absent radial pulse post-fracture suggests compartment syndrome or arterial injury, risking ischemia. This confirms vascular compromise, guiding interventions like fasciotomy, addressing the pathophysiological threat to limb viability, ensuring timely treatment.
Choice D reason: Notifying the provider follows assessment. Absent radial pulse suggests compartment syndrome, where swelling impairs arterial flow. Neurovascular assessment quantifies severity (e.g., pallor, paresthesia), ensuring accurate reporting for urgent intervention, preventing delays in treating vascular compromise critical to limb preservation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The client’s belief in a chip in his head indicates paranoid ideation, a disturbed thought process in schizophrenia, driven by dopamine dysregulation in the mesolimbic pathway. This nursing problem targets altered reality perception, guiding antipsychotic therapy to reduce delusions, addressing the core cognitive disturbance observed.
Choice B reason: Disturbed sensory perception implies hallucinations, not delusions. The chip belief is a paranoid delusion, not a sensory issue or grandiose belief. Schizophrenia involves cognitive distortions, and “disturbed thought process” better addresses the paranoid ideation, focusing on the neurobiological basis of delusional thinking over sensory misperceptions.
Choice C reason: Impaired verbal communication is inaccurate, as the client is alert and oriented with coherent, though tangential, speech. The chip delusion reflects a thought disorder, not communication deficit. Schizophrenia’s cognitive symptoms prioritize addressing thought processes, driven by neurotransmitter imbalances, over verbal expression issues.
Choice D reason: Impaired social interaction may result from paranoid delusions but is secondary. The primary issue is the disturbed thought process causing the chip delusion, rooted in dopamine dysregulation. Addressing the delusion directly with antipsychotics is more specific, as social issues stem from this core cognitive disturbance.
Correct Answer is C
Explanation
Choice A reason: Denying muscle spasms is normal and not a complication. Muscle twitching indicates hypocalcemia, a thyroidectomy risk due to parathyroid damage. Absence of spasms is reassuring, per postoperative complication monitoring and endocrine surgical care standards in nursing.
Choice B reason: Back and joint pain are nonspecific and not typical thyroidectomy complications. Muscle twitching suggests hypocalcemia, a critical issue post-thyroidectomy. Pain requires assessment but is less urgent, per postoperative monitoring and complication management protocols in surgical nursing.
Choice C reason: Muscle twitching in hands and feet indicates hypocalcemia, a serious complication from parathyroid gland damage during thyroidectomy. This requires immediate calcium replacement to prevent tetany, per postoperative complication monitoring and endocrine surgical care protocols in nursing practice.
Choice D reason: Diaphoresis without headache is nonspecific and not a primary thyroidectomy complication. Muscle twitching signals hypocalcemia, needing urgent intervention. Diaphoresis requires monitoring but is less critical, per postoperative assessment and complication management standards in surgical nursing.
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