A nurse is assessing a client who is in skeletal traction for a fractured left tibia. The nurse should identify that which of the following findings indicates altered tissue perfusion of the affected extremity?
Pain with movement of the left great toe
Faint pedal pulse of left leg
Warm skin temperature distal to pin site
Purulent drainage at the pin site
The Correct Answer is B
Choice A reason:
Pain with movement of the left great toe is incorrect finding: Pain may be expected in a client with a fractured left tibia, especially if the great toe is moved. Pain is more related to the fracture and may not specifically indicate altered tissue perfusion.
Choice B reason:
Faint pedal pulse of the left leg is correct because it indicates that the blood flow to the foot is diminished. The pedal pulse is the pulse felt on the top of the foot, and its faintness could suggest reduced arterial blood flow to the foot.
Choice C reason:
Warm skin temperature distal to the pin site is incorrect: Warm skin distal to the pin site may indicate adequate blood flow and could be a normal finding. Warmth is generally associated with increased blood flow to the area.
Choice D reason:
Purulent drainage at the pin site is incorrect. Purulent drainage at the pin site could indicate an infection, but it is not directly related to altered tissue perfusion. Infection can lead to complications, but it does not necessarily indicate reduced blood flow to the extremity
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Arching should not be expected. Arching of the body is not a typical manifestation of bacterial pneumonia. It may be seen in infants with certain conditions such as abdominal pain or neurologic issues, but it is not specific to pneumonia.
Choice B reason:
Drooling should not be expected. Drooling is not a common manifestation of bacterial pneumonia. It may be seen in certain conditions affecting the throat or mouth, but it is not directly related to pneumonia.
Choice C reason:
Fever is the correct answer. Bacterial pneumonia is an infection in the lungs caused by bacteria. When a child has bacterial pneumonia, their body's immune system responds to the infection, leading to inflammation and fever.
Choice D reason:
Steatorrhea should not be expected. Steatorrhea refers to fatty, bulky, and foul-smelling stools and is not associated with bacterial pneumonia. Steatorrhea may be seen in conditions affecting the gastrointestinal system and fat absorption.
Choice E reason:
Tinnitus should not be expected. Tinnitus is the perception of noise or ringing in the ears and is not a typical manifestation of bacterial pneumonia. Tinnitus can be associated with various ear-related conditions or medication side effects, but it is not directly related to pneumonia.
Correct Answer is ["A","B"]
Explanation
A: Correct. Broccoli is a vegetable that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.
B: Correct. Yogurt is a dairy product that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.
C: Incorrect. Pepperoni pizza contains pepperoni, cheese, and tomato sauce, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.
D: Incorrect. Cream cheese is a dairy product that contains tyramine, which can interact with phenelzine and cause a hypertensive crisis.
E: Incorrect. Bologna sandwich contains bologna, bread, and mayonnaise, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.
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