This is the edited text:

An nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. What is included in the evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.)

Color

Temperature

Ecchymosis

Skin integrity

Sensation

Answer and Explanation

Correct Answer : A,B,E

Choice A reason: Color is an important indicator of the blood flow and oxygenation to the affected extremity. The nurse should compare the color of the skin, nails, and mucous membranes of the affected and unaffected extremities and look for any signs of pallor, cyanosis, or mottling. These signs can indicate ischemia, hypoxia, or impaired circulation, which can lead to tissue damage or necrosis.

Choice B reason: Temperature is another important indicator of the blood flow and oxygenation to the affected extremity. The nurse should compare the temperature of the skin of the affected and unaffected extremities by palpating with the back of the hand and look for any signs of warmth or coolness. These signs can indicate inflammation, infection, or reduced perfusion, which can affect the healing process or cause complications.

Choice C reason: Ecchymosis is not an indicator of the neurovascular status of the affected extremity. Ecchymosis is the discoloration of the skin caused by bleeding under the skin, which can result from trauma, surgery, or anticoagulant therapy. Ecchymosis is expected after an ORIF of a femur fracture and does not necessarily indicate a problem with the blood flow or oxygenation to the extremity.

Choice D reason: Skin integrity is not an indicator of the neurovascular status of the affected extremity. Skin integrity is the condition of the skin and its ability to resist damage, infection, or breakdown. Skin integrity can be affected by factors such as pressure, friction, moisture, or foreign bodies. The nurse should assess the skin integrity of the affected extremity and look for any signs of wounds, ulcers, or infections, but these signs do not reflect the neurovascular status of the extremity.

Choice E reason: Sensation is an important indicator of the nerve function and innervation of the affected extremity. The nurse should assess the sensation of the affected extremity by asking the client to report any numbness, tingling, or pain, or by testing the client's response to light touch, pressure, or temperature. These signs can indicate nerve damage, compression, or irritation, which can affect the mobility and function of the extremity.

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Correct Answer is C

Explanation

Choice A reason: Higherthannormal number of CD4+ Tcells and CD8+ Tcells are normal is not a laboratory value that most adults with human immunodeficiency virus will exhibit, because it does not reflect the effect of the virus on the immune system. CD4+ Tcells and CD8+ Tcells are types of white blood cells that play a key role in the immune response. CD4+ Tcells are helper cells that activate and coordinate other immune cells, while CD8+ Tcells are cytotoxic cells that kill infected or abnormal cells. Human immunodeficiency virus infects and destroys CD4+ Tcells, which impairs the immune function and increases the risk of opportunistic infections and cancers. CD8+ Tcells are not directly affected by the virus, but they may increase in number as a compensatory mechanism to fight the infection. Therefore, most adults with human immunodeficiency virus will have lowerthannormal number of CD4+ Tcells and higher than normal CD8+ Tcells.

Choice B reason: Lowerthannormal number of CD4+ Tcells and CD8+ Tcells are normal is not a laboratory value that most adults with human immunodeficiency virus will exhibit, because it does not reflect the effect of the virus on the immune system, as explained above. Lowerthannormal number of CD4+ Tcells and CD8+ Tcells are normal may indicate a condition that affects both types of Tcells, such as aplastic anemia, chemotherapy, radiation therapy, or immunosuppressive drugs.

Choice C reason: Lowerthannormal number of CD4+ Tcells and higher than normal CD8+ Tcells is a laboratory value that most adults with human immunodeficiency virus will exhibit, because it reflects the effect of the virus on the immune system, as explained above. Lowerthannormal number of CD4+ Tcells and higher than normal CD8+ Tcells may indicate the progression of the infection and the severity of the immunodeficiency. The normal range of CD4+ Tcells is 500 to 1500 cells per microliter of blood, while the normal range of CD8+ Tcells is 150 to 1000 cells per microliter of blood.

Choice D reason: Higherthannormal number of CD4+ Tcells and CD8+ Tcells are low is not a laboratory value that most adults with human immunodeficiency virus will exhibit, because it does not reflect the effect of the virus on the immune system, as explained above. Higherthannormal number of CD4+ Tcells and CD8+ Tcells are low may indicate a condition that affects CD8+ Tcells, such as leukemia, lymphoma, or corticosteroid therapy.

A. The client has a butterfly rash B. Blood pressure of 126/85 mm Hg C. The client reports chronic fatigue D. Urine output of 20 mL/hour

Correct Answer is D

Explanation

Choice A reason: The client having a butterfly rash is not a concerning finding in a client with SLE. A butterfly rash is a malar rash that appears across the cheeks and the bridge of the nose. It is a common sign of SLE and may flare up or fade depending on the disease activity. It does not indicate any serious complication or organ damage.

Choice B reason: A blood pressure of 126/85 mm Hg is not a concerning finding in a client with SLE. This blood pressure is within the normal range and does not indicate hypertension or hypotension. Hypertension is a possible complication of SLE that may affect the kidneys, the heart, or the brain. Hypotension may indicate shock, dehydration, or infection.

Choice C reason: The client reporting chronic fatigue is not a concerning finding in a client with SLE. Chronic fatigue is a common symptom of SLE that affects the quality of life and the ability to perform daily activities. It may be caused by inflammation, pain, anemia, depression, or medication side effects. It does not indicate any acute or lifethreatening condition.

Choice D reason: A urine output of 20 mL/hour is a concerning finding in a client with SLE. This urine output is below the normal range of 30 to 50 mL/hour and indicates oliguria, which is a reduced urine production. Oliguria may indicate acute kidney injury, which is a serious complication of SLE that may lead to renal failure or death. The nurse should monitor the client's urine output, fluid balance, electrolytes, and kidney function and report any abnormal findings to the provider.

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This is the edited text:An nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. What is included in the evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.)

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This is the edited text:

An nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. What is included in the evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.)