A nurse is caring for a client who has musculoskeletal injuries to the left lower extremity. Which of the following assessments should the nurse perform to evaluate the neurovascular status of the client's extremity?
Check skin temperature distal to the injury with the dorsum of the hand.
Press the heel of the foot to determine capillary refill.
Monitor sensation by palpating the pad of the great toe with a blunt needle.
Compare the color of the skin proximal to the injury with the other extremity.
The Correct Answer is A
A. Check skin temperature distal to the injury with the dorsum of the hand.: Assessing skin temperature distal to the injury is an important part of evaluating neurovascular status. It helps to identify any changes in circulation or potential complications like ischemia. The dorsum of the hand is commonly used as it provides a good comparison to the temperature of the affected extremity.
B. Press the heel of the foot to determine capillary refill.: While capillary refill is an important assessment, it is usually measured by pressing the nail beds or pads of the fingers and toes, not by pressing the heel. This method does not provide a reliable indication of neurovascular status.
C. Monitor sensation by palpating the pad of the great toe with a blunt needle.: While assessing sensation is important, it is typically done using a light touch or pinprick, rather than palpating with a blunt needle. The use of a needle is not standard practice for this type of assessment.
D. Compare the color of the skin proximal to the injury with the other extremity.: Comparing the skin color distal to the injury with the unaffected extremity is more relevant for evaluating neurovascular status. Proximal comparison is less effective in assessing circulation and potential issues related to the injury.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B,C,E,A,D
Explanation
B. Attach the spacer.: Attaching the spacer first ensures that the inhaler is properly connected and ready for use.
C. Shake the inhaler.: Shaking the inhaler is essential to mix the medication thoroughly before use.
E. Place lips around the mouthpiece.: Placing the lips around the mouthpiece is done while the inhaler is ready to be activated.
A. Press down on the canister top.: Pressing the canister releases the medication into the spacer, which the client will then inhale.
D. Hold breath for 10 seconds.: Holding the breath allows the medication to be fully absorbed into the lungs.
Correct Answer is B
Explanation
Rationale:
A. Levothyroxine is used to treat hypothyroidism, not hyperthyroidism. In a Thyroid storm, thyroid hormone levels are already dangerously elevated. Giving levothyroxine would worsen the condition and increase metabolic demand further.
B. Thyroid storm causes a severe hypermetabolic state, increasing oxygen consumption and demand. Supplemental oxygen helps; prevent hypoxia, support tissues under metabolic stress, reduce risk of organ failure. Therefore making it an important supportive, priority intervention.
C. Clients in thyroid storm typically have high fever (hyperthermia). The appropriate intervention is cooling measures (cooling blankets, antipyretics), not warming. Warm blankets would worsen hyperthermia.
D. Thyroid storm causes tachycardia (very fast heart rate) and risk of arrhythmias. Increasing the pulse rate would increase risk of complications such as heart failure. Therefore the goal is to decrease heart rate (e.g., beta-blockers) and reduce cardiac workload
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