After falling down the basement steps, a client is brought to the emergency room. The x-ray confirms the client's right leg is fractured. Following the application of a leg cast, which assessment finding warrants immediate intervention by the nurse?
Reports throbbing right leg pain.
Circumferential edema of right foot.
Increased temperature to lower extremity.
Right foot pale with sluggish capillary refill.
The Correct Answer is D
A. Throbbing pain can be a common response after a fracture and cast application but does not necessarily indicate an emergency situation.
B. Circumferential edema could suggest complications, but it is not as immediately concerning as the vascular status of the limb.
C. An increased temperature in the lower extremity could indicate inflammation or infection, but it does not require immediate intervention compared to signs of impaired circulation.
D. A pale foot with sluggish capillary refill suggests compromised blood flow, which is a medical emergency requiring immediate assessment and intervention to prevent ischemia or compartment syndrome.
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Correct Answer is C
Explanation
A. While frequent mouth care is important, it is not the most immediate concern during an active seizure. The priority is to maintain airway patency and prevent aspiration.
B. Maintaining a semi-Fowler's position may be beneficial, but the client’s level of consciousness and the presence of seizures require more immediate interventions focused on airway management.
C. Ensuring oral suction is available is essential for the client who is unconscious and experiencing seizures, as it allows for rapid intervention to clear secretions and prevent aspiration, which is critical for airway protection.
D. Keeping the room at a comfortable temperature is important for the overall comfort of the client, but it does not directly address the acute management of seizures and airway concerns.
Correct Answer is B
Explanation
A. A soft diet may not provide sufficient fiber, which is essential for managing diverticulosis and preventing complications such as diverticulitis.
B. A high fiber diet helps to bulk up stool and promotes regular bowel movements, reducing the risk of complications associated with diverticulosis. Increased fluid intake is also essential to help fiber work effectively in the digestive system.
C. While sitting up after meals can aid digestion, it is not a primary dietary instruction for managing diverticulosis.
D. A bland diet may not be necessary; the focus should be on increasing fiber intake rather than avoiding specific flavors or spices unless they cause discomfort.