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 D,A,B,C
No explanation
Correct Answer is A
Explanation
Choice A rationale
Collecting objects like rocks reflects the interest in categorizing and organizing, which aligns with the industry vs. inferiority stage for school-age children.
Choice B rationale
Wanting to do well in school also fits with the industry vs. inferiority stage, where children gain pride from achieving tasks and being competent.
Choice C rationale
Doing simple math problems in one's head indicates cognitive development but doesn't directly align with the psychosocial development focus.
Choice D rationale
Following rules set by parents is important, but it's more about conforming to authority rather than indicating psychosocial development specific to industry vs. inferiority.
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