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An nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. What is included in the evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.)
Color
Temperature
Ecchymosis
Skin integrity
Sensation
Correct Answer : A,B,E
Choice A reason: Color is an important indicator of the blood flow and oxygenation to the affected extremity. The nurse should compare the color of the skin, nails, and mucous membranes of the affected and unaffected extremities and look for any signs of pallor, cyanosis, or mottling. These signs can indicate ischemia, hypoxia, or impaired circulation, which can lead to tissue damage or necrosis.
Choice B reason: Temperature is another important indicator of the blood flow and oxygenation to the affected extremity. The nurse should compare the temperature of the skin of the affected and unaffected extremities by palpating with the back of the hand and look for any signs of warmth or coolness. These signs can indicate inflammation, infection, or reduced perfusion, which can affect the healing process or cause complications.
Choice C reason: Ecchymosis is not an indicator of the neurovascular status of the affected extremity. Ecchymosis is the discoloration of the skin caused by bleeding under the skin, which can result from trauma, surgery, or anticoagulant therapy. Ecchymosis is expected after an ORIF of a femur fracture and does not necessarily indicate a problem with the blood flow or oxygenation to the extremity.
Choice D reason: Skin integrity is not an indicator of the neurovascular status of the affected extremity. Skin integrity is the condition of the skin and its ability to resist damage, infection, or breakdown. Skin integrity can be affected by factors such as pressure, friction, moisture, or foreign bodies. The nurse should assess the skin integrity of the affected extremity and look for any signs of wounds, ulcers, or infections, but these signs do not reflect the neurovascular status of the extremity.
Choice E reason: Sensation is an important indicator of the nerve function and innervation of the affected extremity. The nurse should assess the sensation of the affected extremity by asking the client to report any numbness, tingling, or pain, or by testing the client's response to light touch, pressure, or temperature. These signs can indicate nerve damage, compression, or irritation, which can affect the mobility and function of the extremity.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Heberden's nodes are not a symptom of lupus. Heberden's nodes are bony swellings that form on the distal interphalangeal joints of the fingers. They are a sign of osteoarthritis, which is a degenerative joint disease that causes pain, stiffness, and reduced mobility.
Choice B reason: Chvostek's sign is not a symptom of lupus. Chvostek's sign is a facial twitch that occurs when the facial nerve is tapped near the ear. It is a sign of hypocalcemia, which is a low level of calcium in the blood. Hypocalcemia may be caused by various conditions, such as hypoparathyroidism, vitamin D deficiency, or renal failure.
Choice C reason: OsgoodSchlatter's disease is not a symptom of lupus. OsgoodSchlatter's disease is a condition that affects the growth plate of the tibia, which is the shin bone. It causes pain, swelling, and tenderness below the knee. It is common in adolescents who are active in sports that involve running, jumping, or bending the knee.
Choice D reason: Butterfly rash is a classic symptom of lupus. Butterfly rash is a malar rash that appears across the cheeks and the bridge of the nose. It is a common sign of systemic lupus erythematosus (SLE), which is an autoimmune disease that causes inflammation and damage to various organs and tissues. The rash may flare up or fade depending on the disease activity and exposure to sunlight.
Correct Answer is B
Explanation
Choice A reason: Creating a susceptible host is not a way to break the chain of infection, but rather a way to facilitate it. A susceptible host is someone who is vulnerable to infection due to factors such as age, immunocompromised status, or chronic diseases.
Choice B reason: Maintaining the integrity of a portal of entry is a way to break the chain of infection, because it prevents the entry of microorganisms into the body. A portal of entry is any place where microorganisms can enter the body, such as the skin, mucous membranes, or respiratory tract. By reducing skin breakdown, the nurse is protecting the skin from becoming a portal of entry for infection.
Choice C reason: Creating a reservoir to decrease the risk of infection is a contradiction, because a reservoir is a place where microorganisms can multiply and survive, such as a human, animal, or environment. A reservoir increases the risk of infection, not decreases it.
Choice D reason: Sterilizing the area to reduce the reservoir risk is a way to break the chain of infection, but it is not related to reducing skin breakdown. Sterilizing the area means killing or removing all microorganisms from a surface or object, such as a surgical instrument or a wound dressing. This can reduce the reservoir risk, but it does not affect the integrity of the skin as a portal of entry.
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