The nurse receives report on four clients who are reporting an increase in pain. Which client requires immediate intervention by the nurse?
Paresthesia of fingers due to carpal tunnel syndrome.
Burning pain due to a Morton's neuroma.
Sharp pain related to a crushed femur.
Stinging pain related to plantar fasciitis.
The Correct Answer is C
Rationale:
A. Paresthesia of fingers due to carpal tunnel syndrome: Carpal tunnel symptoms typically progress slowly and are not life-threatening. While uncomfortable, they do not require urgent intervention unless accompanied by signs of severe nerve damage.
B. Burning pain due to a Morton’s neuroma: Morton’s neuroma causes localized nerve pain in the foot and may impair mobility, but it is not considered an emergency. It usually responds to conservative treatment and is not limb-threatening.
C. Sharp pain related to a crushed femur: A crushed femur can result in severe bleeding, compartment syndrome, or fat embolism—each of which can be life-threatening. Immediate assessment and intervention are critical to prevent complications like shock or loss of limb function.
D. Stinging pain related to plantar fasciitis: Plantar fasciitis causes chronic heel pain, especially with movement, but it is not emergent. It requires treatment for pain relief and inflammation but does not pose an immediate risk to life or limb.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. The left radial pulse is 2+ bounding: A radial pulse reflects arterial blood flow but does not confirm the functionality of the AV fistula. It may be normal even if the fistula is occluded or nonfunctional.
B. Assessment of a bruit on the left forearm: A bruit, a whooshing sound heard with a stethoscope, indicates turbulent blood flow through the AV fistula, confirming that the fistula is patent and functioning. This is a key sign of fistula viability.
C. Auscultation of a thrill on the left forearm: A thrill is felt (palpated), not auscultated. While a thrill is also a sign of patency, the phrasing here is incorrect. The term “auscultation” applies to the bruit, not the thrill.
D. Distended, tortuous veins in the left hand: Prominent hand veins may occur with vascular changes but do not confirm AV fistula patency. Assessment must include direct evaluation for a bruit or thrill over the fistula site.
Correct Answer is ["A","E"]
Explanation
Rationale:
A. Separate fluids from meals: Fluids should be consumed at least 30 minutes before or after meals to prevent gastric overdistention and dumping syndrome, which are common after bariatric surgery.
B. Plan meals to include rice porridge: Rice porridge is high in simple carbohydrates, which can cause dumping syndrome and rapid gastric emptying. It is not ideal post-surgery.
C. Eliminate acidic food choices: Acidic foods like citrus or tomatoes may cause discomfort, but they are not universally contraindicated. Tolerance varies by individual, so elimination is not routinely necessary.
D. Offer more bread and cheese: Bread can form a sticky bolus that’s hard to swallow post-op, and cheese is high in fat. Both can cause discomfort or intolerance early in recovery.
E. Provide small frequent meals: After bariatric surgery, the stomach’s capacity is reduced, so clients need to eat small, frequent meals to meet nutritional needs and prevent nausea or vomiting.
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