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Twelve hours after experiencing a traumatic closed fracture of the lower left tibia, a client reports pain, tingling, and diminished toe movement in the left foot. Which nursing problem has the highest priority based on this information?

Impaired comfort.

Impaired skin integrity.

Risk for infection related to traumatic fracture.

Risk for peripheral neurovascular dysfunction.

Answer and Explanation

The Correct Answer is D

A. While impaired comfort is a concern, the priority is to address potential neurovascular compromise.

B. Impaired skin integrity is a concern but not the most immediate issue given the symptoms described.

C. Risk for infection is important but secondary to the acute concern of neurovascular function.

D. Risk for peripheral neurovascular dysfunction is the highest priority as it indicates potential compartment syndrome or other serious complications requiring urgent intervention.

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Correct Answer is B

Explanation

A. Ignoring the client's behavior (putting it on extinction) may escalate the situation, as clients with antisocial behavior often do not respond well to being ignored.

B. Informing him that the nurse is busy and will talk to him later sets clear boundaries while acknowledging his request. It helps manage his behavior without reinforcing negative actions.

C. Encouraging him to talk with another nurse may not address his immediate need for attention and could result in further disruptive behavior.

D. Introducing him to the newly admitted client may not be appropriate as it could disrupt the admission process and potentially intimidate the new client.

A. "After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, but it goes away." B. "I have a hard time inhaling and holding my breath after I squeeze the inhaler, but I do my best." C. "I never use the inhaler unless I am feeling really short of breath." D. "I always shake the inhaler several times before I start."

Correct Answer is A

Explanation

A. The statement indicates that the client is swallowing the medication rather than inhaling it, which suggests improper use of the inhaler.

B. Difficulty inhaling and holding breath can occur with proper use but does not necessarily indicate incorrect technique.

C. While using the inhaler only when very short of breath may not be optimal management, it does not indicate incorrect use of the inhaler itself.

D. Shaking the inhaler before use is a correct technique to ensure proper medication delivery.

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Twelve hours after experiencing a traumatic closed fracture of the lower left tibia, a client reports pain, tingling, and diminished toe movement in the left foot. Which nursing problem has the highest priority based on this information?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The psychiatric nurse is talking to a newly admitted client when another male client, who is diagnosed with antisocial behavior, intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" How should the nurse respond to this client?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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