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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Rationale:

A. A family member expresses concern about their relative "picking" at the nasogastric (NG) tube: Family concern should be acknowledged, but restraint use must be based on clinical necessity. The nurse can first implement non-restrictive interventions before considering restraints.

B. A client is walking the halls at night rubbing his hands together: This behavior does not indicate harm to self or others or interference with medical devices. There is no justification for restraint, and doing so could violate patient rights and ethical standards.

C. A 16-year-old boy swung his fist at the nurse: This may call for emergency behavioral restraints rather than mitten restraints. If the behavior poses a threat of violence, other forms of crisis intervention or behavioral management should be pursued first.

D. A disoriented client removed the mesh-wrapped intravenous (IV) line for the second time: Mitten restraints may be considered when a client repeatedly removes critical lines or tubes, especially when cognitively impaired. This situation meets the clinical indication for discussing their use with the provider to prevent treatment disruption while ensuring safety.

A. Arrange for an unlicensed assistive personnel to assist the PN during the procedure. B. Acknowledge that the PN has positioned the client safely and correctly. C. Assume care of the client and assign the PN to the care of a different client. D. Demonstrate to the PN how to position the client more effectively for the procedure.

Correct Answer is D

Explanation

Rationale:

A. Arrange for an unlicensed assistive personnel to assist the PN during the procedure:
The issue is not lack of assistance, but incorrect positioning. Adding support staff doesn’t correct the improper technique for lumbar puncture preparation.

B. Acknowledge that the PN has positioned the client safely and correctly: For a lumbar puncture, the client should be in a lateral recumbent position with knees on both legs, not just the left, pulled up to the chest and the neck flexed.

C. Assume care of the client and assign the PN to the care of a different client: This approach is punitive and misses a teaching opportunity. It’s more effective to correct the error and provide guidance for future practice.

D. Demonstrate to the PN how to position the client more effectively for the procedure:
This promotes safe care while supporting the PN’s learning. Demonstrating the correct positioning ensures immediate correction and improves future practice.

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The nurse receives report on four clients who are reporting an increase in pain. Which client requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which situation indicates a need for the nurse to discuss the use of mitten restraints with the healthcare provider?

Correct Answer is D

Explanation

The nurse observes a practical nurse (PN) placing a client on the right side with the left leg bent in preparation for a lumbar puncture. Which action should the nurse implement?

Correct Answer is D

Explanation

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