A nurse assesses an audible grating sound (crepitus) when a client with osteoarthritis moves his knees. What is the cause of this sound?

Choice A reason: This is the highest priority client because sudden and increasing pain in a fractured arm can indicate a complication, such as compartment syndrome, infection, or nerve damage. Compartment syndrome is a condition where the pressure inside the muscles increases to dangerous levels, causing severe pain, reduced blood flow, and tissue death. Infection is a condition where microorganisms invade the wound site, causing inflammation, pus, and fever. Nerve damage is a condition where the nerves are injured by the fracture, causing numbness, tingling, or weakness. The nurse should see this client first and assess the arm for any signs of these complications, such as swelling, pallor, loss of sensation, or impaired movement. The nurse should also elevate the arm, loosen any bandages or casts, and administer pain medication as ordered.

Choice B reason: This is not the highest priority client because a fractured ankle is a common and stable condition that affects the lower extremity. A glass of water is a comfort and hydration need that can be met by the nurse or another staff member. The nurse should see this client after the more urgent clients and provide the glass of water, as well as monitor the ankle for any signs of complications, such as edema, infection, or impaired circulation.

Choice C reason: This is not the highest priority client because rheumatoid arthritis is a chronic and manageable condition that affects the joints. A scheduled pain medication is a routine and preventive need that can be met by the nurse or another staff member. The nurse should see this client after the more urgent clients and administer the pain medication, as well as assess the joints for any signs of inflammation, stiffness, or deformity.

Choice D reason: This is not the highest priority client because a discharge teaching is a discharge and education need that can be met by the nurse or another staff member. The nurse should see this client last and teach the client how to use the crutches, as well as provide any other discharge instructions, such as wound care, activity restrictions, or followup appointments.

Choice A reason: Color is an important indicator of the blood flow and oxygenation to the affected extremity. The nurse should compare the color of the skin, nails, and mucous membranes of the affected and unaffected extremities and look for any signs of pallor, cyanosis, or mottling. These signs can indicate ischemia, hypoxia, or impaired circulation, which can lead to tissue damage or necrosis.

Choice B reason: Temperature is another important indicator of the blood flow and oxygenation to the affected extremity. The nurse should compare the temperature of the skin of the affected and unaffected extremities by palpating with the back of the hand and look for any signs of warmth or coolness. These signs can indicate inflammation, infection, or reduced perfusion, which can affect the healing process or cause complications.

Choice C reason: Ecchymosis is not an indicator of the neurovascular status of the affected extremity. Ecchymosis is the discoloration of the skin caused by bleeding under the skin, which can result from trauma, surgery, or anticoagulant therapy. Ecchymosis is expected after an ORIF of a femur fracture and does not necessarily indicate a problem with the blood flow or oxygenation to the extremity.

Choice D reason: Skin integrity is not an indicator of the neurovascular status of the affected extremity. Skin integrity is the condition of the skin and its ability to resist damage, infection, or breakdown. Skin integrity can be affected by factors such as pressure, friction, moisture, or foreign bodies. The nurse should assess the skin integrity of the affected extremity and look for any signs of wounds, ulcers, or infections, but these signs do not reflect the neurovascular status of the extremity.

Choice E reason: Sensation is an important indicator of the nerve function and innervation of the affected extremity. The nurse should assess the sensation of the affected extremity by asking the client to report any numbness, tingling, or pain, or by testing the client's response to light touch, pressure, or temperature. These signs can indicate nerve damage, compression, or irritation, which can affect the mobility and function of the extremity.