A nurse is caring for a client postoperative closed reduction of the left ankle with a short cast in place. Which assessments of the client's affected leg should the nurse make? (SELECT ALL THAT APPLY)

Capillary refill

Pain assessment on a scale of 0-10

Ability to move toes

Posterior tibialis and pedal pulses

Skin temperature and color of the toes

Answer and Explanation

Correct Answer : A,B,C,D,E

A. Capillary refill is a key indicator of circulation to the affected area. It should be assessed to ensure adequate perfusion.

B. Pain assessment is critical for identifying any complications such as compartment syndrome or inadequate pain management.

C. The ability to move the toes helps assess for nerve function and mobility.

D. Posterior tibialis and pedal pulses assess the circulation and can help identify signs of vascular compromise.

E. Skin temperature and color help identify signs of poor circulation, swelling, or potential complications like compartment syndrome.

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Correct Answer is B

Explanation

A. The CPM machine does not affect wound drainage directly.

B. The CPM machine helps reduce pain by promoting circulation and decreasing joint stiffness.

C. Physical therapy is still necessary alongside CPM usage.

D. The primary purpose is to maintain joint mobility, not directly strengthen the leg.

A. The cartilage in the joint wears away from constant use and causes pain. B. The body is misinterpreting non-painful stimuli as pain. C. There are crystals in the joint which cause inflammation and pain. D. The body is attacking the joint lining causing inflammation and joint destruction.

Correct Answer is D

Explanation

A. This description is more characteristic of osteoarthritis, where cartilage wear and tear occur.

B. This explanation is more related to chronic pain syndromes, not specifically RA.

C. The presence of crystals in the joint is a characteristic of gout, not RA.

D. Rheumatoid arthritis (RA) is an autoimmune condition in which the body’s immune system attacks the synovial lining of the joints, causing inflammation, pain, and eventually joint destruction.

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A nurse is caring for a client postoperative closed reduction of the left ankle with a short cast in place. Which assessments of the client's affected leg should the nurse make? (SELECT ALL THAT APPLY)

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