An elderly patient who had a fall at a store is admitted with a potential right hip fracture.
What assessment finding should the nurse report to the healthcare provider?
The left lower extremity is warm to touch.
Bilateral pedal pulses are present and strong.
The patient wiggles their right toes when the sole of the right foot is tickled.
The right leg is externally rotated and shorter than the left.
The Correct Answer is D
Choice A rationale
While it’s important to assess all aspects of the patient’s condition, a warm left lower extremity does not necessarily indicate a right hip fracture. It could be related to other conditions, such as deep vein thrombosis or cellulitis.
Choice B rationale
The presence of strong bilateral pedal pulses is a positive sign and does not indicate a hip fracture. It suggests that the patient has good peripheral circulation.
Choice C rationale
The ability to wiggle the toes when the sole of the right foot is tickled does not necessarily indicate a hip fracture. This is a normal response and suggests that the patient has intact sensory and motor function in the foot.
Choice D rationale
A right leg that is externally rotated and shorter than the left is a classic sign of a hip fracture. This occurs because the fracture can cause the femoral head to tilt and rotate outward, making the leg appear shorter.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A thick, dry, and dark area on the heels could indicate a more advanced stage of a pressure injury, not the earliest indication.
Choice B rationale
Broken skin without evidence of undermining could also indicate a more advanced stage of a pressure injury.
Choice C rationale
A defined area of persistent redness over a bony prominence is often the earliest sign of a developing pressure injury. This is because these areas are more susceptible to pressure and have less padding to protect them.
Choice D rationale
A superficial sacral pressure injury with defined margins is a more advanced stage of a pressure injury.
Correct Answer is ["A","C","D","E","F"]
Explanation
Choice A rationale
An increased pulse rate can be a sign of pain in infants. The heart rate increases as the body’s way of coping with the stress of pain.
Choice B rationale
Skin showing peripheral pallor is not typically associated with pain. It can be a sign of other conditions, such as anemia or shock, but it’s not a reliable indicator of pain.
Choice C rationale
Clenched fists can be a sign of pain in infants. It’s a common non-verbal cue that infants use to express discomfort.
Choice D rationale
An increased respiratory rate can also be a sign of pain. Like an increased heart rate, it’s a physiological response to stress.
Choice E rationale
Restlessness can be a sign of discomfort or pain in infants. Infants may squirm, fidget, or have trouble settling down when they’re in pain.
Choice F rationale
An elevated temperature is not typically a direct sign of pain, but it can indicate an underlying condition that might be causing pain, such as an infection.
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