A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?
Ecchymosis on the inner left thigh
One fingerbreadth of space between the cast and the skin
Diminished pulses on the affected extremity
Client report of muscle spasms of the left leg
The Correct Answer is C
c. Diminished pulses on the affected extremity. This finding may indicate compromised circulation, which is
a serious complication that requires immediate intervention.
Option a. Ecchymosis on the inner left thigh may be a concerning finding, but it is not as urgent as diminished pulses. Ecchymosis may be a result of trauma during cast application, and may resolve on its own.
Option b. One fingerbreadth of space between the cast and the skin is a normal finding and indicates that the cast is not too tight.
Option d. Client report of muscle spasms of the left leg is a common complaint in clients with casts and may
be addressed with medication or other interventions, but it is not as urgent as diminished pulses. Therefore, the priority finding in this scenario is c. Diminished pulses on the affected extremity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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