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 C
Explanation
C. Erythrocyte sedimentation rate (ESR) is a blood test that measures the rate at which red blood cells settle in a tube of blood over time. ESR levels are commonly elevated in inflammatory conditions such as RA.
A. Rheumatoid factor (RF) is an autoantibody commonly found in individuals with rheumatoid arthritis (RA). However, monitoring RF levels is not typically used to evaluate the effectiveness of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) in managing RA symptoms.
B. ANA levels are not typically monitored to evaluate the effectiveness of aspirin or NSAIDs in managing RA symptoms.
D. Monitoring WBC count is important for assessing overall health and detecting infections but it is not specific to evaluating the effectiveness of aspirin or NSAIDs in managing RA symptoms.
Correct Answer is A
Explanation
A. Checking capillary refill distal to the cast helps assess peripheral circulation and nerve function. A decrease in capillary refill time or other signs of compromised circulation (such as coolness, pallor, or numbness) could indicate a complication like compartment syndrome, which requires immediate intervention.
B. Performing range of motion exercises is important for promoting joint mobility and preventing stiffness, but it is not the priority immediately after the cast application.
C. Educating the client about cast care is important for promoting healing and preventing complications, but it is not the priority immediately after the cast application.
D. Managing pain is important for the client's comfort and well-being, but it is not the priority immediately after the cast application.
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