While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following findings should the nurse identify as a complication to the client's condition?

Uneven cast drying

Infection

Pressure from the cast

Poor circulation

Answer and Explanation

The Correct Answer is B

The nurse should identify infection as a complication to the client's condition. A warm area on the cast could indicate the presence of an underlying infection. The warmth could be due to an increase in blood ﬂow to the area as the body tries to fight oﬀ the infection.

Uneven cast drying, pressure from the cast, and poor circulation are not complications that would cause a warm area on the cast. Uneven cast drying could cause discomfort but would not result in warmth. Pressure from the cast could cause skin breakdown but would not result in warmth. Poor circulation could cause coolness or pallor but would not result in warmth.

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Correct Answer is A

Explanation

The first action the nurse should take is to test the drainage for glucose. Clear drainage from the nose following a basal skull fracture could indicate a cerebrospinal ﬂuid (CSF) leak. CSF contains glucose, so testing the drainage for glucose can help determine if it is CSF.

b. Taking the client's temperature is not the first action the nurse should take.
c. Notifying the charge nurse is important but not the first action the nurse should take.
d. Placing a dressing under the client's nose is not the first action the nurse should take.

A. Extension of the extremities B. External rotation of the lower extremities C. Pronation of the hands D. Plantar ﬂexion of the legs

Correct Answer is D

Explanation

a. Decorticate posturing is marked by the flexion of the arms, with the hands clenched into fists and the legs extended and internally rotated.
b. External rotation of the lower extremities is not a characteristic of decorticate posturing. In decorticate posture, legs are held out straight.

c.Pronation of the hands is characteristic of decerebrate posturing, where the arms are extended and pronated.

d. In decorticate posturing, the lower extremities typically exhibit plantar flexion. Additionally, the upper extremities show flexion of the arms, wrists, and fingers with adduction of the arms.

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While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following findings should the nurse identify as a complication to the client's condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's right nostril. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who has a knee injury. When describing range-of-motion exercises, the nurse should explain that the knee is which of the following types of joints?

A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?

A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?

A nurse in a long-term care facility finds an older adult client lying on the ﬂoor next to the bed. Which of the following actions should the nurse take?

A nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?

A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.)

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