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A client has suffered from a femur fracture. What is the nurse’s priority assessment?
Pain
Medication history
Socioeconomic status
Pedal pulses
The Correct Answer is D
Choice A reason: This is not the priority assessment, but it is an important assessment for a client with a femur fracture. Pain is the unpleasant sensation that results from tissue damage or inflammation. Pain can affect the client's physical and psychological wellbeing and interfere with their recovery. The nurse should assess the client's pain level, location, quality, and duration using a valid and reliable pain scale. The nurse should also provide pain relief measures, such as medication, ice, elevation, or distraction, as ordered and as needed.
Choice B reason: This is not the priority assessment, but it is a relevant assessment for a client with a femur fracture. Medication history is the record of the drugs that the client is currently taking or has taken in the past, including prescription, overthecounter, herbal, or recreational drugs. Medication history can help the nurse identify any potential drug interactions, allergies, or contraindications that may affect the client's treatment and recovery. The nurse should ask the client about their medication history and document it accurately and completely.
Choice C reason: This is not the priority assessment, but it is a helpful assessment for a client with a femur fracture. Socioeconomic status is the measure of the client's income, education, occupation, and social class. Socioeconomic status can influence the client's access to health care, ability to afford treatment, compliance with therapy, and support system. The nurse should assess the client's socioeconomic status and provide appropriate referrals, resources, or assistance as needed.
Choice D reason: This is the priority assessment for a client with a femur fracture. Pedal pulses are the pulses that can be felt in the feet, such as the dorsalis pedis or the posterior tibial pulse. Pedal pulses can indicate the blood flow and perfusion to the lower extremities, which can be compromised by a femur fracture. A femur fracture can cause bleeding, swelling, or pressure that can reduce or obstruct the blood supply to the feet, leading to ischemia, necrosis, or gangrene. The nurse should assess the client's pedal pulses regularly and report any changes, such as absent, weak, or thready pulses. The nurse should also monitor the client's skin color, temperature, sensation, and movement in the feet.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Flushing the exposed skin with water is the first action that the nurse should take if they are stuck by a needle. This is to reduce the amount of blood or body fluid that may have entered the wound and to prevent infection. The nurse should flush the skin for at least 15 minutes and avoid using soap, antiseptic, or bleach as they may damage the skin or increase the risk of infection.
Choice B reason: Reporting the exposure is the second action that the nurse should take after flushing the exposed skin with water. This is to inform the supervisor, the occupational health department, or the infection control team about the incident and to initiate the postexposure protocol. The nurse should provide the details of the exposure, such as the type and source of the needle, the depth and location of the wound, and the status of the source patient.
Choice C reason: Seeking medical attention is the third action that the nurse should take after reporting the exposure. This is to receive a medical evaluation and treatment, such as testing, prophylaxis, counseling, and followup. The nurse should consult a health care provider as soon as possible and follow the recommendations for preventing or treating any potential infections, such as hepatitis B, hepatitis C, or HIV.
Choice D reason: Completing an incident report is the last action that the nurse should take after seeking medical attention. This is to document the exposure and the actions taken and to identify the causes and the preventive measures for the future. The nurse should fill out the incident report form accurately and objectively and submit it to the appropriate authority. The incident report is not a part of the client's record and should not be mentioned in the client's chart.
Correct Answer is A
Explanation
Choice A reason: Joint pain with swelling is the correct answer, because it is a common symptom of SLE. SLE is a chronic autoimmune disease that causes inflammation and damage to various organs and tissues, such as the skin, joints, kidneys, heart, and blood vessels. Joint pain with swelling is caused by the inflammation of the synovial membrane that lines the joints, which can lead to stiffness, reduced mobility, and deformity.
Choice B reason: Intense wrinkles is not the correct answer, because it is not a symptom of SLE. Intense wrinkles are a cosmetic issue that affects the appearance of the skin, not the function of the organs or tissues. Intense wrinkles are caused by the loss of collagen and elasticity in the skin, which can result from aging, sun exposure, smoking, or dehydration.
Choice C reason: Raynaud's phenomenon is not the correct answer, because it is not a symptom of SLE. Raynaud's phenomenon is a condition that affects the blood flow to the fingers and toes, not the joints or other organs. Raynaud's phenomenon is caused by the narrowing of the small arteries that supply blood to the extremities, which can result from cold, stress, or other factors.
Choice D reason: Tachycardia is not the correct answer, because it is not a symptom of SLE. Tachycardia is a condition that affects the heart rate, not the joints or other organs. Tachycardia is caused by the abnormal electrical activity of the heart, which can result from anxiety, fever, infection, or other causes.
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