A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?
Mild erythema
Serosanguineous drainage
Fever
Warmth
The Correct Answer is C
A. Mild erythema (redness) at the pin sites can be a normal finding due to the body's response to the presence of foreign objects. It may not necessarily indicate infection.
B. Serosanguineous drainage (a mixture of clear and bloody fluid) can also be a normal finding initially after the insertion of pins. It may not necessarily indicate infection.
C. Fever is a systemic response to infection. In a client with skeletal traction, fever can be an indication of an infection at the pin sites or a more systemic infection related to the traction device.
D. Warmth around the pin sites can be a normal finding due to the inflammatory response that occurs after pin insertion. It may not necessarily indicate infection.
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Correct Answer is C
Explanation
A. Stating that ibuprofen is the first step in medication therapy for osteoarthritis is not an accurate statement. Medication choices should be made in consultation with a healthcare provider, and different medications may be prescribed based on individual needs.
B. Elevating the legs with pillows is generally not a specific intervention for osteoarthritis in the knees. While elevation can help with other conditions, it is not a primary recommendation for managing knee osteoarthritis.
C. Using either heat or ice can be helpful in relieving discomfort associated with osteoarthritis. This statement indicates an understanding of self-care strategies for managing symptoms.
D. Limiting physical activity is not typically recommended for osteoarthritis management. In fact, regular and appropriate physical activity can be beneficial for maintaining joint function and reducing pain in individuals with osteoarthritis.
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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