A nurse is collecting data from a client who has a long leg cast that was applied 2 days ago. Which of the following findings should the nurse report to the provider?

Client has a capillary refill of 3 seconds in the toes of the affected extremity.

Client reports increasing pain in the affected extremity.

Client's toes of the affected extremity feel warm to the touch.

Client reports itching beneath the cast.

Answer and Explanation

The Correct Answer is B

A long leg cast is a rigid external device applied to immobilize fractures, facilitate bone healing, and prevent displacement of musculoskeletal structures. Because a cast is unyielding, it can become a hazardous structural barrier if the soft tissues beneath it begin to swell excessively. The nurse must perform diligent neurovascular assessments, monitoring peripheral perfusion, nerve function, and tissue pressure, to identify early signs of vascular compromise or compartment syndrome before irreversible ischemic injury occurs.

Rationale:

A. A capillary refill of 3 seconds in the toes of the affected extremity is a sluggish finding, but it does not represent the most critical, immediate threat to the client. Although a normal capillary refill time is less than 2 seconds, a reading of 3 seconds can sometimes be influenced by environmental coolness or standard, non-compromised post-injury edema. While it requires ongoing tracking, it does not supersede a finding of progressive, severe physiological pain.

B. A client reporting increasing pain in the affected extremity is a critical finding that the nurse must report to the provider immediately. Pain that intensifies over time, especially 48 hours after application and despite the administration of prescribed analgesics, is the primary, most reliable indicator of compartment syndrome. This occurs when localized tissue swelling outpaces the fixed volume of the cast, severely increasing pressure within the muscle compartment, cutting off microvascular blood flow, and threatening tissue viability.

C. The finding that the client's toes of the affected extremity feel warm to the touch is a normal, reassuring indication of adequate arterial perfusion. Warm skin indicates that oxygenated blood is successfully reaching the most distal portions of the immobilized limb. The nurse would be concerned if the toes felt cold, pale, or cyanotic, which would signify arterial insufficiency or severe venous stasis.

D. A client reporting itching beneath the cast is a very common, expected discomfort associated with prolonged skin immobilization, localized perspiration, and natural skin desquamation (shedding). While annoying for the client, it is not a dangerous physiological threat. The nurse should instruct the client never to insert sharp objects, hangers, or pencils beneath the cast to scratch, as this can break skin integrity and cause hidden infections.

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Correct Answer is A

Explanation

Clients receiving a terminal diagnosis often experience intense emotional reactions such as shock, sadness, anger, or fear. Nursing care in this situation focuses on therapeutic communication, emotional support, and presence rather than providing false reassurance or shifting focus too quickly to problem-solving. The nurse’s role is to acknowledge feelings, promote trust, and provide a supportive environment that allows the client to express emotions safely. Effective communication can reduce distress and enhance coping during this critical period.

Rationale:
A. Offering to stay with the client demonstrates therapeutic presence and emotional support, which is appropriate when caring for a client experiencing distress due to a diagnosis such as Terminal illness. This response validates the client’s emotions and provides reassurance through presence rather than false promises. It promotes trust and allows the client to process feelings at their own pace.

B. Stating that everything will be fine provides false reassurance, which is nontherapeutic because it minimizes the client’s feelings and may reduce trust in the nurse. In terminal diagnoses, outcomes are uncertain or poor, so such reassurance is inappropriate and misleading.

C. Asking about hospice care is premature because the client is currently expressing emotional distress that requires immediate support and presence. Introducing care planning too early may shift focus away from the client’s emotional needs. Therapeutic communication should first address feelings before discussing options.

D. Contacting caregivers may be helpful later, but immediately doing so without the client’s input may reduce opportunities for the client to express emotions privately. The priority is providing emotional support and therapeutic presence before involving others in the discussion.

A. Tachycardia B. Elevated temperature C. Cramping D. Seizures

Correct Answer is D

Explanation

Acute alcohol withdrawal occurs when a client with chronic alcohol use abruptly reduces or stops alcohol intake, leading to central nervous system hyperactivity. Manifestations can range from mild tremors and anxiety to severe complications such as delirium tremens and seizures. Nursing priorities focus on identifying life-threatening complications early, maintaining airway and safety, and preventing neurologic deterioration. Seizures are especially concerning because they can rapidly progress to respiratory compromise, aspiration, or injury.

Rationale:
A. Tachycardia is a common finding during alcohol withdrawal due to autonomic nervous system stimulation. Although it indicates physiologic stress and may require monitoring, it is not the highest priority finding. It does not pose the same immediate risk to life as neurologic complications such as seizures.

B. Elevated temperature can occur during severe withdrawal and may suggest autonomic instability or developing delirium tremens. While fever requires assessment and intervention, it is not as immediately life-threatening as seizure activity. Priority is given to findings that threaten airway, breathing, or circulation first.

C. Cramping may occur as part of generalized discomfort or electrolyte imbalance during withdrawal, but it is not considered a critical complication. Muscle cramps do not pose an immediate risk of injury or cardiopulmonary compromise compared with severe neurologic manifestations.

D. Seizures are the priority because they are a potentially life-threatening complication of Alcohol withdrawal syndrome. Withdrawal seizures can lead to aspiration, trauma, hypoxia, and progression to status epilepticus. Immediate intervention and close monitoring are necessary to protect airway and prevent serious complications.

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A nurse is collecting data from a client who has a long leg cast that was applied 2 days ago. Which of the following findings should the nurse report to the provider?

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