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).

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

A properly fastened harness and securely anchored car seat are essential for infant safety. This statement indicates correct practice and does not require further teaching.

Choice B rationale

Using an infant model car seat that is securely anchored is appropriate for a 6-month-old infant. This statement is correct and does not indicate a need for further teaching.

Choice C rationale

A front-facing car seat is inappropriate for a 6-month-old infant. Infants should ride in a rear-facing car seat until at least the age of 2 or until they reach the highest weight or height allowed by the car seat manufacturer. This statement indicates a need for further teaching.

Choice D rationale

A rear-facing car seat in the back passenger seat is the safest position for a 6-month-old infant. This statement is correct and does not indicate a need for further teaching.

A. Autonomy. B. Initiative. C. Identity. D. Trust.

Correct Answer is C

Explanation

Choice A rationale

Autonomy is a developmental task of toddlers (1-3 years old), focusing on developing a sense of personal control over physical skills and independence.

Choice B rationale

Initiative is a developmental task of early childhood (3-6 years old), where children begin to assert control and power over their environment through directing play and other social interactions.

Choice C rationale

Identity is the primary developmental task of adolescents (12-18 years old), focusing on developing a personal sense of self and direction in life.

Choice D rationale

Trust is a developmental task of infancy (0-1 year), where children learn to trust their caregivers for care and sustenance.

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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?

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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?