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 C
Explanation
Choice A rationale
Watermelon with seeds poses a choking hazard for young children, making it an unsafe food choice. The seeds can easily get stuck in a child’s throat, leading to potential airway obstruction. Additionally, small children might not have the coordination to properly spit out seeds, increasing the risk of accidental swallowing and subsequent choking. Therefore, whole fruits with seeds are generally recommended to be avoided for toddlers.
Choice B rationale
Raw carrots are another choking hazard for young children due to their hard texture. Toddlers might not have developed the necessary chewing skills to safely eat raw vegetables, increasing the risk of choking. Small, hard foods like raw carrots can be difficult to chew and swallow, making them unsafe for children under the age of three. Cooked or finely chopped vegetables are safer alternatives.
Choice C rationale
Mashed potatoes are a safe and appropriate food choice for a 14-month-old child. They are soft, easy to chew, and swallow, reducing the risk of choking. Mashed potatoes can be easily modified to suit the nutritional needs and texture preferences of young children. They can also be fortified with other healthy ingredients like pureed vegetables or proteins to make a balanced meal for toddlers.
Choice D rationale
Popcorn is a known choking hazard for young children and is not recommended for those under the age of four. Popcorn kernels are small, hard, and irregularly shaped, making them difficult for young children to chew and swallow safely. The risk of choking on popcorn is high due to its propensity to lodge in the airway, causing potentially serious complications. .
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