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 C
Explanation
A. Immediately after the patient has been medicated for pain.
While pain relief may help, education should be conducted when the patient is alert and comfortable, not immediately after pain medication when they may be drowsy.
B. The last thing in the evening, after visitors have left, before bedtime. Education right before bedtime may not be effective if the patient is tired, as retention and attention may be reduced.
C. When the patient is comfortable and receptive to the patient education.
Teaching should occur when the patient is comfortable, alert, and receptive to ensure they can retain and understand the information.
D. Just before the patient is discharged, so the information is current.
Waiting until discharge could overwhelm the patient, and they may not have time to ask questions or clarify information.
Correct Answer is C
Explanation
A. Clear, dark amber-colored urine may indicate dehydration or concentrated urine, which does not necessarily signify improvement in liver function or treatment efficacy.
B. A prothrombin time within normal limits may indicate improved liver function; however, it is not the primary goal of the treatment plan focused on managing ascites and fluid retention in cirrhosis.
C. Decreased abdominal girth is a key indicator of progress in managing fluid retention associated with cirrhosis, as the treatment plan aims to reduce ascites through a low sodium diet and albumin infusions.
D. Improved level of consciousness is essential for overall recovery but is not the primary measure of progress related to fluid management and treatment effects in this context.