The nurse performing a neurovascular check on a limb in traction would report and document which finding(s) as indicative of altered circulation? (Select the 2 correct answers)
Distal limb can be flexed and stretched
Cap refill >5 sec.
Pulse is equal to unaffected limb
Limb is cool to touch
Patient is aware of touch and warm and cold application
Correct Answer : B,D
A. The ability to flex and stretch the distal limb indicates intact motor function, not altered circulation.
B. A capillary refill time greater than 5 seconds suggests poor peripheral perfusion and possible vascular compromise.
C. A pulse equal to the unaffected limb indicates normal circulation.
D. A limb that is cool to touch suggests decreased blood flow and impaired circulation.
E. Patient awareness of touch and temperature indicates intact sensory function, not circulation issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. MS is believed to be an autoimmune disorder where the immune system attacks the myelin sheath, but it is not simply a hypersensitivity reaction.
B. Current evidence suggests that a combination of environmental factors (such as viral infections, vitamin D deficiency) and genetic predisposition contribute to the development of MS.
C. Allergic responses to antiviral medications are not linked to causing MS.
D. MS is not caused by a bacterial infection of the myelin; it is an autoimmune demyelinating disease.
Correct Answer is A
Explanation
A. A lumbar punctureis the most important diagnostic test for suspected bacterial meningitis. It allows for analysis and culture of cerebrospinal fluid (CSF)to identify the presence of bacteria, white blood cells, protein, and glucose levels.
B. Cerebral angiography is used to visualize blood vessels in the brain, not to diagnose infections like meningitis.
C. Myelography evaluates the spinal cord, nerve roots, and spinal canal using contrast dye but is not used for diagnosing meningitis.
D. Magnetoencephalography (MEG) is used to map brain activity, often for epilepsy or brain tumors, and is not relevant for diagnosing meningitis.
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