This is the edited text:
A client has suffered from a femur fracture. What is the nurse’s priority assessment?
Pain
Medication history
Socioeconomic status
Pedal pulses
The Correct Answer is D
Choice A reason: This is not the priority assessment, but it is an important assessment for a client with a femur fracture. Pain is the unpleasant sensation that results from tissue damage or inflammation. Pain can affect the client's physical and psychological wellbeing and interfere with their recovery. The nurse should assess the client's pain level, location, quality, and duration using a valid and reliable pain scale. The nurse should also provide pain relief measures, such as medication, ice, elevation, or distraction, as ordered and as needed.
Choice B reason: This is not the priority assessment, but it is a relevant assessment for a client with a femur fracture. Medication history is the record of the drugs that the client is currently taking or has taken in the past, including prescription, overthecounter, herbal, or recreational drugs. Medication history can help the nurse identify any potential drug interactions, allergies, or contraindications that may affect the client's treatment and recovery. The nurse should ask the client about their medication history and document it accurately and completely.
Choice C reason: This is not the priority assessment, but it is a helpful assessment for a client with a femur fracture. Socioeconomic status is the measure of the client's income, education, occupation, and social class. Socioeconomic status can influence the client's access to health care, ability to afford treatment, compliance with therapy, and support system. The nurse should assess the client's socioeconomic status and provide appropriate referrals, resources, or assistance as needed.
Choice D reason: This is the priority assessment for a client with a femur fracture. Pedal pulses are the pulses that can be felt in the feet, such as the dorsalis pedis or the posterior tibial pulse. Pedal pulses can indicate the blood flow and perfusion to the lower extremities, which can be compromised by a femur fracture. A femur fracture can cause bleeding, swelling, or pressure that can reduce or obstruct the blood supply to the feet, leading to ischemia, necrosis, or gangrene. The nurse should assess the client's pedal pulses regularly and report any changes, such as absent, weak, or thready pulses. The nurse should also monitor the client's skin color, temperature, sensation, and movement in the feet.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: "You should never go around people after your baby is born." is not a good response, because it is unrealistic, rigid, and dismissive of the mother's concern. It does not acknowledge the benefits of social interaction and support for the mother and the baby, nor the risks of isolation and depression. It also does not provide any evidence or rationale for the advice.
Choice B reason: "Tell me more about that." is the best response, because it is openended, empathetic, and respectful of the mother's concern. It invites the mother to share her feelings and thoughts, and allows the nurse to explore the source and extent of the mother's anxiety. It also creates an opportunity for the nurse to provide education and reassurance based on the mother's needs.
Choice C reason: "I did that, and my kids turned out just fine." is not a good response, because it is personal, irrelevant, and unprofessional. It does not address the mother's concern, but rather shifts the focus to the nurse's own experience, which may not be applicable or helpful to the mother. It also implies that the mother's concern is unfounded or exaggerated, and may make the mother feel judged or defensive.
Choice D reason: "Why do you think that is a bad idea?" is not a good response, because it is closedended, confrontational, and accusatory. It does not show empathy or respect for the mother's concern, but rather challenges or criticizes it. It may make the mother feel defensive or guilty, and may discourage further communication.
Correct Answer is B
Explanation
Choice A reason: Providing active range of motion (ROM) is not a treatment that the nurse can perform for a quadriplegic client. Active ROM means that the client moves their own joints without assistance. A quadriplegic client has paralysis of all four limbs and cannot move their joints voluntarily.
Choice B reason: Providing passive range of motion (ROM) is a treatment that the nurse can perform for a quadriplegic client. Passive ROM means that the nurse moves the client's joints through their full range of motion without resistance. This helps prevent joint contracture, which is the loss of joint movement and flexibility due to muscle shortening and stiffness. It also helps maintain joint mobility, which is the ability of the joint to move smoothly and freely.
Choice C reason: Turning the client every 2 hours is not a treatment that the nurse can perform to decrease the risk of joint contracture and promote joint mobility. Turning the client every 2 hours is a preventive measure to avoid pressure ulcers, which are skin injuries caused by prolonged pressure on the skin. It does not directly affect the joint function or movement.
Choice D reason: Administering glucosamine supplements is not a treatment that the nurse can perform to decrease the risk of joint contracture and promote joint mobility. Glucosamine supplements are dietary supplements that may help reduce the pain and inflammation of osteoarthritis, which is a degenerative joint disease that causes the breakdown of the cartilage and bone in the joints. It does not affect the muscle or nerve function or movement.
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