A nurse is assessing a client who has just had a lower-leg cast application to stabilize an ankle fracture. Which of the following findings in the affected extremity is the nurse's priority?
Mild edema to the toes.
Ecchymosis at the base of the toes
Numbness in the toes
Pain at the fracture site with movement
The Correct Answer is C
A. Mild edema to the toes: Mild swelling is a common and expected finding after a cast application due to trauma and immobility. It should be monitored but is not an immediate concern unless it progresses or is accompanied by other symptoms.
B. Ecchymosis at the base of the toes: Bruising near the injury site is also expected following a fracture and cast application. While it should be documented, it does not typically indicate a complication unless associated with worsening symptoms.
C. Numbness in the toes: Numbness may signal impaired nerve function or compromised circulation due to increased pressure from the cast, raising concern for compartment syndrome. This requires immediate evaluation to prevent permanent damage.
D. Pain at the fracture site with movement: Some pain is normal after a fracture and casting, particularly with movement. However, it becomes more concerning if it is severe, unrelieved by medication, or accompanied by signs of neurovascular compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Liver function tests:Valproic acid is hepatotoxic and can lead to serious liver injury, especially in the early months of therapy. Baseline liver function tests (LFTs) are essential to assess hepatic status and establish a comparison point for future monitoring during treatment.
B. Potassium level:While important for general health, potassium is not directly affected by valproic acid. Valproic acid does not typically cause significant alterations in potassium, making this lab less relevant as a baseline before the first dose.
C. Uric acid level:Uric acid levels are more commonly associated with conditions like gout or medications like diuretics. Valproic acid does not impact uric acid metabolism, so this is not a priority lab for initiating therapy.
D. Thyroid function tests:Thyroid monitoring is more relevant for medications like lithium, which can cause hypothyroidism. Valproic acid does not typically interfere with thyroid function, so TSH or T4 levels are not necessary at baseline.
Correct Answer is B
Explanation
A. Have the client drink 360 mL (12 oz) of plain water: While rehydration is important, plain water alone may not be sufficient to replace lost electrolytes in heat exhaustion. Oral rehydration with electrolyte-containing fluids is usually preferred.
B. Place the client in a cool environment: Moving the client to a shaded or air-conditioned environment is essential to reduce core body temperature and prevent progression to heat stroke. This is a priority action in treating heat exhaustion.
C. Immerse the client in ice water: Ice water immersion is used in severe heat stroke, not heat exhaustion. It may cause vasoconstriction and shivering, which can worsen the condition if used prematurely.
D. Give the client salt tablets: Salt tablets are not recommended due to the risk of gastrointestinal irritation and potential for sodium overload. Balanced electrolyte fluids are a safer and more effective way to restore electrolyte balance.
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