A nurse is assessing a client who reports a nevus that has increased in size and an irregularly shaped lesion that varies in color. These findings are consistent with which of the following medical diagnoses?

Choice A reason:

Measuring the circumference of the thigh can be part of the assessment for swelling or edema, which may indicate compartment syndrome or other issues. However, it is not a direct measure of neurovascular status, which focuses on blood flow and nerve function.

Choice B reason:

Palpating the femoral pulse is important for assessing blood flow to the leg, but for a midshaft femur fracture, more distal pulses such as the popliteal, dorsalis pedis, or posterior tibial pulses would be more indicative of the neurovascular status of the affected limb.

Choice C reason:

Monitoring the client's calf for edema is a useful technique for identifying signs of swelling that could suggest complications like deep vein thrombosis or compartment syndrome. However, it does not provide a complete picture of neurovascular integrity, which also includes sensory and motor function assessment.

Choice D reason:

Instructing the client to wiggle his toes is a direct assessment of motor function, which is a key component of neurovascular status. This action, along with checking for sensation and capillary refill, helps to determine if there is any impairment in nerve function or blood supply to the affected area.

The correct answer is: a. Temperature, c. Color, d. Sensation.

Choice A: Temperature

Reason: Monitoring the temperature of the affected extremity is crucial in evaluating neurovascular status. A cool or cold extremity can indicate decreased perfusion, which may be a sign of neurovascular compromise. Normal skin temperature should be warm to the touch, indicating adequate blood flow.

Choice B: Ecchymosis

Reason: Ecchymosis, or bruising, is not a direct indicator of neurovascular status. While it can provide information about trauma or bleeding, it does not assess the functionality of nerves or blood vessels in the affected extremity.

Choice C: Color

Reason: Assessing the color of the extremity is essential. Pallor or cyanosis can indicate poor blood flow or oxygenation, which are critical signs of neurovascular impairment. Normal color should be consistent with the rest of the body, indicating good circulation.

Choice D: Sensation

Reason: Evaluating sensation helps determine if there is any nerve damage or impairment. Changes in sensation, such as numbness or tingling, can indicate neurovascular compromise. Normal sensation should be intact and symmetrical with the unaffected extremity.

Choice E: Skin Integrity

Reason: While skin integrity is important for overall wound healing and infection prevention, it is not a primary parameter for assessing neurovascular status. It does not provide direct information about blood flow or nerve function.