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 D

Explanation

Choice A reason: Use gentle brushing and flossing techniques for clients with fragile mucosa is an important nursing intervention, but it is not the priority. Gentle brushing and flossing can help prevent plaque, gingivitis, and infection in the oral cavity, especially for clients with fragile mucosa due to dehydration, medication, or radiation. However, this intervention is not as urgent as having a suction apparatus ready at the bedside.

Choice B reason: Handle dentures with care is an important nursing intervention, but it is not the priority. Handling dentures with care can prevent damage, loss, or misplacement of the dentures, which can affect the client's comfort, appearance, and nutrition. However, this intervention is not as urgent as having a suction apparatus ready at the bedside.

Choice C reason: Position the client on one side with the head turned towards you is an important nursing intervention, but it is not the priority. Positioning the client on one side with the head turned towards you can facilitate the access and visibility of the oral cavity, as well as prevent the aspiration of saliva, blood, or debris. However, this intervention is not as effective as having a suction apparatus ready at the bedside.

Choice D reason: Have a suction apparatus ready at the bedside is the priority nursing intervention, because it can prevent the aspiration of saliva, blood, or debris, which can cause choking, pneumonia, or respiratory distress. Having a suction apparatus ready at the bedside can allow the nurse to quickly and safely remove any secretions or foreign materials from the oral cavity or the airway of the unconscious client.

A. "If I am reexposed to HIV, the progression to AIDS may be faster." B. "My diet does not influence the progression of HIV to AIDS." C. "If I practice meditation, I may develop AIDS faster." D. "Sexually transmitted infections will not make AIDS develop faster."

Correct Answer is A

Explanation

Choice A reason: This is the correct statement because it reflects the fact that reexposure to HIV can increase the viral load and accelerate the decline of the immune system. HIV is a virus that infects and destroys the CD4 cells, which are the white blood cells that help fight infections. AIDS is the final stage of HIV infection, when the CD4 count falls below 200 cells/mm3 or the client develops an opportunistic infection. The progression from HIV to AIDS can vary from person to person, depending on several factors, such as viral strain, genetic factors, treatment adherence, and coinfections. Reexposure to HIV can expose the client to a different or more aggressive strain of the virus, which can overwhelm the immune system and hasten the development of AIDS.

Choice B reason: This is an incorrect statement because it ignores the role of nutrition in maintaining the health and function of the immune system. Diet can influence the progression of HIV to AIDS by affecting the client's weight, energy, metabolism, and susceptibility to infections. The client should eat a balanced and varied diet that provides adequate calories, protein, vitamins, minerals, and fluids. The client should also avoid foods that can cause diarrhea, dehydration, or food poisoning, which can worsen the symptoms and complications of HIV infection.

Choice C reason: This is an incorrect statement because it contradicts the evidence that shows that meditation can have positive effects on the psychological and physiological wellbeing of people living with HIV. Meditation is a mindbody practice that involves focusing attention on the present moment, breathing, and relaxation. Meditation can help the client cope with stress, anxiety, depression, and pain, which are common challenges for people living with HIV. Meditation can also improve the immune system function by reducing inflammation, oxidative stress, and cortisol levels, which can slow down the progression of HIV to AIDS.

Choice D reason: This is an incorrect statement because it overlooks the impact of sexually transmitted infections (STIs) on the course of HIV infection. STIs can increase the risk of transmitting and acquiring HIV by causing ulcers, inflammation, or bleeding in the genital area, which can facilitate the entry and exit of the virus. STIs can also increase the viral load and decrease the CD4 count, which can speed up the progression of HIV to AIDS. The client should practice safe sex by using condoms, getting tested and treated for STIs, and informing their sexual partners about their HIV status.

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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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Explanation

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Explanation

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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.)