Following a fractured left tibia, which necessitated placement of long leg cast, a client is using crutches to ambulate. During an orthopedic follow-up visit, a client reports to the nurse having difficulty managing the crutches. Which assessment should the nurse perform?
Measure capillary refill time.
Palpate for dependent edema.
Determine degree of skin elasticity.
Note hand and forearm strength.
The Correct Answer is D
A. Capillary refill time assessment is more relevant for circulatory status and would not directly address the client's difficulty with crutch management.
B. Palpating for dependent edema would not provide information directly related to the client's ability to use crutches.
C. Assessing skin elasticity is not directly related to the client's ability to manage crutches.
D. Strength in the hands and forearms is essential for proper crutch use, as these muscles bear much of the weight while ambulating with crutches.
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Related Questions
Correct Answer is D
Explanation
A. Ensuring that someone stays with the client for 24 hours is important for immediate postoperative care but does not directly ensure compliance with self-care instructions.
B. Having the client vocalize the instructions ensures that the client understands and can recall the information provided, which is crucial for compliance with self-care. However, it does not provide a point of reference while at home.
C. Speaking clearly and facing the client for lip reading is helpful for communication but does not ensure that the client fully understands and can follow the instructions.
D. Providing written instructions is crucial because written instructions can serve as a reference for the client to review as needed, ensuring they understand and follow the postoperative care procedures, which is essential for preventing complications and promoting healing.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Uremic Encephalopathy: The client has chronic kidney disease and elevated blood urea nitrogen (BUN) levels, indicating impaired kidney function. Symptoms such as feeling tired, fever, and possibly altered mental status can be associated with uremic encephalopathy, a condition that arises from the accumulation of toxins in the blood due to kidney failure.
Fluid Volume Overload: The client has elevated blood pressure (140/86 mm Hg), an irregular and elevated heart rate (117 beats/minute), and respiratory rate (36 breaths/minute), which can be signs of fluid volume overload. Additionally, the slight bibasilar infiltrates observed in the chest X-ray suggest potential fluid accumulation in the lungs.
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