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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
A. Encouraging physical activity, such as walking, is important for cardiovascular health, but it is not a measurable outcome related to the client's current condition of blurred vision and cardiovascular disease.
B. While educating the family about signs and symptoms is valuable, it does not directly address the client's health status or outcomes that can be measured.
C. A target blood pressure of less than 160/90 mm Hg does not adequately control hypertension and may still pose a risk to cardiovascular health, especially given the blurred vision, which could indicate possible complications.
D. Setting a goal for the client’s daily blood pressure to be less than 140/80 mm Hg is a clear, measurable outcome that indicates effective management of hypertension and promotes overall cardiovascular health. This target is aligned with current clinical guidelines for hypertension management.
Correct Answer is C
Explanation
A. Oxycodone is an opioid analgesic used for moderate to severe pain management but is not typically the first-line medication in acute coronary syndrome scenarios.
B. Fentanyl is a potent opioid that may be used for severe pain; however, morphine is more commonly used in emergency situations for chest pain related to potential myocardial infarction.
C. Morphine is commonly used in emergency departments for the management of acute chest pain, particularly when associated with myocardial ischemia. It helps reduce pain and anxiety, lowers myocardial oxygen demand, and has vasodilatory effects that can alleviate the burden on the heart.
D. Hydromorphone is another opioid analgesic but is not usually the preferred choice for chest pain in the acute setting compared to morphine.