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Exhibits

Highlight the assessment findings that require follow-up by the nurse.

The client is postoperative below-the-knee amputation right leg day 3. He is sitting up with his left leg and right leg residual limb hanging off the bed. There is client-controlled analgesia (PCA) of morphine on demand in the left hand area; there is no redness at the site with 0.9% sodium chloride infusing at 50 mL an hour.

General: Alert, oriented to person, place, and time.

Eyes Pupils round, reactive to light and accommodation (PERRLA).

Lungs: Lungs clear all lobes.

Heart Telemetry monitor displaying sinus rhythm (SR).

Abdomen: Abdomen soft, bowel sounds in all 4 quadrants. Denies pain with urination and describes urine as light yellow.

Right leg: Right leg incision is open to air skin to the area is cool to touch and edema noted along the incision. Sutures intact, no redness noted, popliteal pulses strong bilaterally and wound drain with approximately 100 ml of drainage present on right leg. Reports pain is a 2 on a 0 to 10 scale, right residual limb area.

Left leg 2+ pedal pulse loss of hair on the lower leg, skin is dry, scaly, cool to touch, thickened toe nails noted, and capillary refill is greater than 4 seconds

cool to touch and edema noted along the incision

wound drain with approximately 100 ml of drainage present

loss of hair on the lower leg

right residual limb area.

capillary refill is greater than 4 seconds

Answer and Explanation

The Correct Answer is ["A","B","C","E","F"]

Right leg: Skin cool to touch with edema along the incision: These signs suggest impaired perfusion and possible early infection or inflammation. Although there's no redness, edema and coolness warrant continued monitoring for progression or signs of infection.
Right leg: 100 mL of wound drainage present: This is a moderately high amount of drainage for postoperative day 3. While not yet excessive, the color, consistency, and ongoing amount must be monitored closely for signs of infection or wound dehiscence.
Left leg: Loss of hair on lower leg, dry/scaly/cool skin: These are classic signs of chronic peripheral arterial disease (PAD), reflecting poor circulation. This limb is also at risk for ischemia and future complications, especially with the client's history of PVD and a recent amputation on the opposite leg.
Left leg: Thickened toenails: This indicates chronic poor circulation and possibly fungal infection or tissue ischemia. It reflects long-standing vascular compromise and should be documented and evaluated by vascular or podiatry teams.
Left leg: Capillary refill greater than 4 seconds: This is a clear indicator of impaired peripheral perfusion. Normal refill is under 2 seconds; delayed refill confirms compromised blood flow and requires further vascular evaluation or intervention.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Teach the client relaxation techniques: While stress reduction can help manage hypermetabolic symptoms associated with Grave’s disease, it does not address the client’s current acute condition. Restlessness and refusal to eat signal an urgent need to stabilize fluid and nutritional deficits before implementing supportive measures like relaxation techniques.

B. Maintain a patent intravenous site: Severe dehydration and malnutrition compromise cardiovascular stability and metabolic function in Grave’s disease, which is already associated with a hypermetabolic state. Ensuring IV access is crucial for administering fluids, electrolytes, and possibly medications to prevent complications such as thyroid storm or cardiac arrhythmias.

C. Keep room temperature cool: Although clients with hyperthyroidism often experience heat intolerance, adjusting the room temperature alone does not address the immediate risks posed by severe dehydration and malnutrition. Environmental comfort is secondary to maintaining physiologic stability through hydration and nutrition support.

D. Determine the client's food preferences: Identifying food preferences is appropriate for long-term nutritional support, but it is not the priority when a client is refusing food and showing signs of serious metabolic derangement. Parenteral or enteral nutrition may be needed first to stabilize the condition.

A. Explain that weight loss will be reversed after the acute phase of the stroke has ended. B. Demonstrate the use of visual scanning during meals to the client and family. C. Suggest that the family bring foods from home that the client enjoys eating. D. Encourage the family to offer to feed the client when she does not eat her entire meal.

Correct Answer is B

Explanation

A. Explain that weight loss will be reversed after the acute phase of the stroke has ended: This response minimizes the family’s concern and overlooks the current nutritional deficit. Waiting for the acute phase to pass without implementing strategies to support nutritional intake can result in malnutrition and delayed recovery.

B. Demonstrate the use of visual scanning during meals to the client and family: Visual perception deficits, such as unilateral neglect, are common after a CVA and may cause the client to ignore food on one side of the tray. Teaching visual scanning techniques helps the client become aware of the neglected side and promotes full food intake, directly addressing the nutritional concern.

C. Suggest that the family bring foods from home that the client enjoys eating: While bringing familiar foods may increase appetite, it does not address the underlying issue of impaired visual perception. Even with preferred foods, the client may still miss food on the affected side, leading to inadequate intake.

D. Encourage the family to offer to feed the client when she does not eat her entire meal: Feeding assistance should only be considered when the client is unable to feed herself. Promoting independence through visual scanning techniques enhances functional recovery and dignity, while dependency can hinder rehabilitation and motivation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult woman with Grave's disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. Which action is most important for the nurse to implement?

Correct Answer is B

Explanation

An older adult client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?

Correct Answer is B

Explanation

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