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A nurse is assisting in the care of a client who is in the emergency department (ED) following a ski accident.

Exhibits

The nurse is collecting data on the client. Which of the following findings require follow up?

Select all that apply.

A.

Findings of right lower extremity assessment

B.

Pain level

C.

Level of consciousness

D.

Oxygen saturation

E.

Right pedal pulses

F.

Temperature

G.

X-ray results

Answer and Explanation

Correct Answer : A,B,E

A. Findings of right lower extremity assessment: The diminished pulses, cool temperature, and reduced sensation of the right foot suggest impaired circulation and potential compartment syndrome, which is an emergency.
B. Pain level: A pain level of 10/10 that is disproportionate to the injury indicates a need for immediate evaluation, as it may signal compartment syndrome.
C. Level of consciousness: Not concerning as the client is alert and denies loss of consciousness.
D. Oxygen saturation: Normal at 97%.
E. Right pedal pulses: A diminished pedal pulse (1+) on the right is a critical finding that requires urgent intervention to restore circulation.
F. Temperature: A temperature of 36°C is within normal limits and does not require follow-up.
G. X-ray results: Confirms the fracture but is not a finding requiring immediate follow-up compared to circulatory concerns.


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Related Questions

Correct Answer is C

Explanation

A. Aspartate aminotransferase (AST) 34 units/L (0 to 34 units/L): This is within the normal range and does not contraindicate a biopsy.
B. Ammonia 55 mcg/dL (10 to 80 mcg/dL): This is within the normal range and does not directly impact the safety of a biopsy.
C. Platelets 60,000/mm3 (150,000 to 400,000/mm3): A low platelet count increases the risk of bleeding during a liver biopsy, as platelets are critical for clotting. This value should be reported before the procedure.
D. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL): This is at the upper limit of normal and does not necessitate reporting in the context of a liver biopsy.

Correct Answer is A

Explanation

A. Changed mental status: Older adults often exhibit atypical signs of infection, such as confusion, agitation, or other changes in mental status, rather than classic symptoms like fever or dysuria.
B. Temperature 37.3° C (99.1° F): This temperature is within normal range and does not indicate an infection. Older adults may not always mount a fever with infections.
C. WBC count 9,000/mm³ (5,000 to 10,000/mm³): This is within the normal range, so it does not suggest infection. An elevated WBC count (>10,000/mm³) may indicate an infection.
D. Diminished reflexes: This is not a symptom of a bladder infection. It is more commonly associated with neurological or musculoskeletal conditions.

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