A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following findings should the nurse expect to observe first?
Inability to move toes.
Pallor of the toes.
Change in temperature of the toes.
Edema of the toes.
The Correct Answer is B
A. Inability to move toes may be a sign of tightness in the cast, but it is not the first finding to be expected if the cast is too tight.
B. Pallor of the toes indicates compromised blood flow and is the earliest sign of circulatory impairment due to tightness of the cast.
C. Change in temperature of the toes may be a sign of impaired circulation, but it is not the earliest finding to be expected.
D. Edema of the toes may occur as a result of compromised circulation, but it is not the first finding to be expected if the cast is too tight.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Avoiding prolonged sitting helps reduce pressure on the lower back and minimizes the risk of developing back strain or pain.
B. Sleeping in a side-lying position with flexed knees helps maintain the natural curvature of the spine and reduces strain on the lower back.
D. Using padded shoe insoles can provide additional support and cushioning to the feet and lower back, helping to reduce strain.
E. Applying heat for short durations can help relax muscles and alleviate muscle tension, which can contribute to back pain relief. However, it's important not to overuse heat, so short intervals are recommended.
Correct Answer is C
Explanation
A. Delaying the surgery until a member of the client's family is reached may not be in the best interest of the client if urgent surgical intervention is indicated.
B. While naloxone can reverse the effects of opioids like morphine, it is not the primary action the neurosurgeon would take in this situation. The priority is addressing the urgent surgical need.
C. Invoking implied consent is the most appropriate action in this situation. Implied consent is assumed in emergency situations where the client is unable to provide consent, and delay would significantly jeopardize the client's health.
D. Asking the client to sign the surgical consent form would not be feasible in this situation since the client is likely not in a condition to provide informed consent due to the administration of intravenous morphine and the urgency of the surgical intervention.
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