A nurse is assessing a client who has a hip fracture. Which of the following findings should the nurse expect?
Muscle spasms
Hip pallor
Leg abduction
Leg lengthening
The Correct Answer is A
A. Muscle spasms can occur in response to the hip fracture as the body attempts to protect the injured area. Spasms may cause pain and muscle rigidity in the affected hip.
B. Pallor refers to paleness of the skin. While hip fractures can result in various signs and symptoms such as pain, swelling, and bruising, hip pallor specifically is not typically associated with a hip fracture.
C. Leg abduction refers to moving the leg away from the midline of the body. In the case of a hip fracture, the affected leg may be held in adduction (closer to the midline) due to pain and muscle guarding.
D. Leg lengthening is not typically associated with a hip fracture. In fact, a hip fracture can often lead to apparent leg shortening due to displacement or angulation of the fractured bone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Tachypnea is a classic early manifestation of fat embolism syndrome. Fat emboli can travel to the lungs and obstruct blood flow, leading to respiratory distress and hypoxemia. Tachypnea is the body's response to hypoxemia, as it attempts to increase oxygen intake by breathing more rapidly.
A. Swelling of the calf can occur with conditions such as deep vein thrombosis (DVT), but it is not typically an early manifestation of fat embolism syndrome.
B. tachycardia is more commonly seen due to the body's response to decreased oxygen levels and increased demand on the cardiovascular system.
C. Hypertension is not typically associated with fat embolism syndrome. Instead, hypotension can occur due to decreased cardiac output and systemic vasodilation in severe cases of fat embolism syndrome.
Correct Answer is ["C","D"]
Explanation
C. Education about the benefits of pain management, including how analgesics can improve postoperative activity levels by reducing pain and discomfort, helps to promote the patient's understanding and engagement in their own care.
D. Nurses should closely monitor the patient for both therapeutic effects and adverse effects of opioid administration when using PCA or any other opioid analgesic. Regular assessment allows for prompt identification and management of any complications or side effects.
A. Patient-controlled analgesia (PCA) is designed for the patient to self-administer pain medication according to their own needs and pain levels.
B. Opioid dosing should be individualized based on the patient's pain level and response to the medication. Some patients may require ongoing opioid analgesia for more than two days postoperatively, while others may be able to transition to alternative pain management strategies sooner.
E. Concerns about opioid addiction should not be assumed in all patients, especially those who have never received opioids before. Instead, the focus should be on assessing the patient's pain levels, response to pain medication, and any adverse effects.
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