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: Creating a susceptible host is not a way to break the chain of infection, but rather a way to facilitate it. A susceptible host is someone who is vulnerable to infection due to factors such as age, immunocompromised status, or chronic diseases.
Choice B reason: Maintaining the integrity of a portal of entry is a way to break the chain of infection, because it prevents the entry of microorganisms into the body. A portal of entry is any place where microorganisms can enter the body, such as the skin, mucous membranes, or respiratory tract. By reducing skin breakdown, the nurse is protecting the skin from becoming a portal of entry for infection.
Choice C reason: Creating a reservoir to decrease the risk of infection is a contradiction, because a reservoir is a place where microorganisms can multiply and survive, such as a human, animal, or environment. A reservoir increases the risk of infection, not decreases it.
Choice D reason: Sterilizing the area to reduce the reservoir risk is a way to break the chain of infection, but it is not related to reducing skin breakdown. Sterilizing the area means killing or removing all microorganisms from a surface or object, such as a surgical instrument or a wound dressing. This can reduce the reservoir risk, but it does not affect the integrity of the skin as a portal of entry.
Correct Answer is ["B","C","E"]
Explanation
Choice A reason: "I will monitor my nutrition and fluid status." is not a statement that requires further teaching or clarification, because it is correct and appropriate. Monitoring nutrition and fluid status is an important selfcare measure for people with HIV, as it can help maintain the immune function, prevent dehydration, and promote healing. People with HIV should eat a balanced and varied diet, drink enough water, and avoid foods or drinks that can cause diarrhea, nausea, or vomiting.
Choice B reason: "Because I have HIV, that means I'm an AIDS patient." is a statement that requires further teaching or clarification, because it is incorrect and misleading. Having HIV does not mean that one has AIDS, but rather that one is at risk of developing AIDS. HIV is the virus that causes AIDS, which is the most advanced stage of the infection. AIDS is diagnosed when the CD4+ Tcell count drops below 200 cells per microliter of blood, or when the person develops one or more opportunistic infections or cancers. People with HIV can delay or prevent the progression to AIDS by taking antiretroviral drugs, which can suppress the viral load and improve the immune function.
Choice C reason: "I can still have unprotected intercourse with my partner since he doesn't have HIV." is a statement that requires further teaching or clarification, because it is incorrect and misleading. Having unprotected intercourse with a partner who does not have HIV is not safe or advisable, as it can expose the partner to the risk of contracting HIV. HIV is transmitted through sexual contact, as well as through blood, semen, vaginal fluid, or breast milk. People with HIV should use condoms or other barrier methods during intercourse, regardless of the HIV status of their partner. People with HIV should also inform their partner about their infection, and encourage them to get tested and treated if needed.
Choice D reason: "I need to ensure that I place my needles in a proper needle disposal container." is not a statement that requires further teaching or clarification, because it is correct and appropriate. Placing needles in a proper needle disposal container is an important infection prevention measure for people with HIV, as it can prevent the accidental or intentional reuse or sharing of needles, which can transmit HIV or other bloodborne diseases. People with HIV should use new and sterile needles for injections, and dispose of them in a punctureresistant and leakproof container, which can be obtained from a pharmacy, clinic, or health department.
Choice E reason: "I can spread this through contact with surfaces, so I need to wear gloves in public." is a statement that requires further teaching or clarification, because it is incorrect and exaggerated. Spreading HIV through contact with surfaces is not possible or likely, as the virus does not survive long outside the body, and is not transmitted by casual contact, such as touching, hugging, or sharing utensils. Wearing gloves in public is not necessary or advisable, as it can create a false sense of security, stigma, or discrimination. People with HIV should practice good hygiene, such as washing hands, covering coughs, and cleaning wounds, but they do not need to wear gloves or other protective equipment in public.
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