An older adult client fell while getting out of bed. Which assessment finding indicates a possible hip fracture?
The client cries out when the nurse attempts to examine him.
The client is extremely confused and trying to get up.
The skin of one leg is cooler than that of the upper extremities,
One leg is shorter than the other and has a protruding bump on the side.
The Correct Answer is D
This finding suggests that the client may have experienced a hip fracture. The shorter leg can be a result of the fractured bone, causing a misalignment or displacement. The protruding bump on the side can be a sign of a dislocated or fractured hip joint. It is important to assess and confirm this suspicion through appropriate diagnostic measures, such as X-rays, to provide the necessary medical intervention and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Bowel sounds are the result of muscular contractions in the intestines, indicating the movement of food, fluids, and gas through the gastrointestinal tract. After surgery, the normal function of the intestines, including peristalsis, may be temporarily impaired. As the intestines recover and regain their normal motility, bowel sounds will become audible.
The return of bowel sounds is an encouraging sign that the gastrointestinal system is starting to function again. It indicates that peristaltic activity has resumed and that the intestines are moving and processing the contents within. This is an essential step in the postoperative recovery process, as it indicates the return of normal gastrointestinal function and can lead to the resumption of oral intake and passage of stool.
While the other options may also be associated with the return of GI function, such as feeling hungry or passing flatus or stool, the presence of bowel sounds is a more reliable and direct assessment finding that indicates the resumption of peristaltic activity.
Correct Answer is C
Explanation
Prednisone is a corticosteroid medication that can increase blood glucose levels by promoting gluconeogenesis (the production of glucose from non-carbohydrate sources) and reducing glucose utilization in the body. This can lead to elevated blood sugar levels, especially in individuals with diabetes. The client's history of urinary tract infection and the use of Prednisone suggest that the infection might have triggered the development of DKA.
It's important to note that DKA can occur even when a person is taking insulin as prescribed and following their diet carefully if other factors contribute to the development of DKA, such as an underlying infection or the use of certain medications like Prednisone. The nurse should further assess the client's condition and notify the healthcare provider to initiate appropriate management for DKA.
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