A nurse is caring for a client following an open reduction and internal fixation of a fractured femur.
Which of the following findings is the nurse's priority?
Headache.
Altered level of consciousness.
Muscle spasms.
Oral temperature of 37.7C (99.86F).
The Correct Answer is B
Choice A rationale
Headache could indicate various conditions but is not immediately life-threatening post-surgery. It may be due to medication or anesthesia but is not the priority.
Choice B rationale
Altered level of consciousness (LOC) is a critical finding. It may indicate complications such as hemorrhage, fat embolism, or hypoxia, which require urgent assessment and intervention.
Choice C rationale
Muscle spasms can be a common symptom post-surgery due to pain or positioning. While they need management, they do not take precedence over LOC changes.
Choice D rationale
An oral temperature of 37.7°C is slightly elevated but not alarming. It may be due to the body's normal inflammatory response post-surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Walks with one hand held typically occurs around 12 months as infants gain balance and coordination for upright movement.
Choice B rationale
Sits unsupported usually happens around 6 months when infants' core muscles are strong enough to hold their torso upright.
Choice C rationale
Turning pages in a book is a fine motor skill that develops around 12 months as hand-eye coordination improves.
Choice D rationale
Rolling from front to back typically occurs around 6 months as infants develop stronger neck and upper body muscles.
Correct Answer is B
Explanation
Choice A rationale
The lap belt fitting snugly over the child's abdomen increases the risk of abdominal injury during a crash.
Choice B rationale
The lap belt fitting low across the child's hips distributes force over stronger bony structures, reducing injury risk.
Choice C rationale
Placing a child in the front seat with a shoulder-only automatic belt does not provide proper restraint and increases injury risk.
Choice D rationale
The shoulder strap crossing just below the child's chin indicates improper fit, posing a risk to the neck in a crash.
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