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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?

A.

Reports throbbing right leg pain.

B.

Circumferential edema of right foot.

C.

Increased temperature to lower extremity.

D.

Right foot pale with sluggish capillary refill.

Answer and Explanation

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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View Related questions

Correct Answer is B

Explanation

A. Removing ink marks can lead to difficulty in accurately targeting the radiation area, so the marks should be left in place until the treatment course is complete.

B. Protecting the skin from sunlight exposure is crucial, as the irradiated skin is more sensitive and at increased risk for sunburn. This recommendation helps to prevent further irritation and damage to the skin during and after treatment.

C. While moisturizing lotions can be beneficial for maintaining skin integrity, they should be used cautiously and only if prescribed by the healthcare provider, as some products may cause irritation.

D. The skin inside the radiation portal site should be washed gently with mild soap and water to keep it clean; avoiding washing is not advisable as it can lead to skin breakdown.

Correct Answer is B

Explanation

A. Eating a protein snack before exercising can help prevent hypoglycemia, but this may not be necessary for every individual and does not address the overall management of diabetes.

B. Understanding the importance of receiving an influenza vaccine annually is crucial for clients with diabetes, as they are at higher risk for complications from influenza and other infections.

C. While it is important to monitor alcohol consumption, the statement may not indicate full understanding of how alcohol can affect blood glucose levels and the potential need for individualized guidance.

D. While using salt, herbs, and spices can enhance food flavor, it does not specifically address diabetes management, particularly regarding sodium intake for individuals at risk for hypertension.

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