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
Placing the infant safety seat in the middle of the back seat away from the windows is the safest position, protecting the child from potential impact during accidents and from direct sunlight or objects coming through windows.
Choice B rationale
Following the child's weight and height is crucial for safely transitioning from an infant car seat to a booster seat. This ensures proper restraint and protection as the child grows.
Choice C rationale
Allowing a baby to watch the driver while in the back seat indicates a forward-facing position, which is unsafe for infants. Rear-facing positions provide the best protection for an infant's head, neck, and spine.
Choice D rationale
Using a previously owned car seat with intact instructions can ensure proper installation and use. However, checking the seat's history and condition is crucial to ensure it meets current safety standards.
Correct Answer is B
Explanation
Choice A rationale
Distracting the child by buying a toy can reinforce the tantrum behavior by teaching the child that tantrums result in rewards. This can lead to an increase in tantrum frequency as the child learns to manipulate situations to get new toys or other desired items.
Choice B rationale
Appearing to ignore the child during a tantrum helps to extinguish the behavior over time. By not giving attention to the tantrum, the child learns that this behavior does not achieve their desired outcome. Consistency is key in this approach to ensure the child understands that tantrums are ineffective.
Choice C rationale
Placing the child in time-out for 3 minutes can be effective in some cases, but it may not be the first recommendation. Time-out removes the child from a stimulating environment and gives them time to calm down. However, it may not address the underlying reasons for the tantrum.
Choice D rationale
Calmly telling the child to stop might not be effective during the peak of a tantrum. Toddlers in the midst of a tantrum often cannot process verbal instructions or reasoning, so this approach may not achieve the desired result.
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