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A client sustained a right leg fracture after an industrial accident and reports tingling and severe pain inside the newly applied plaster cast. Upon inspection, the nurse noted that the exposed toes were cyanotic. What is the most appropriate nursing intervention?
- A. Apply heat packs on the leg
- B. Elevate the affected extremity
- C. Contact the physician immediately
- D. Instruct the client to move or wiggle their toes
Correct Answer: C
Rationale: Tingling, severe pain, and cyanotic toes suggest compartment syndrome, a medical emergency. Contacting the physician immediately is critical for evaluation and possible intervention like cast removal or fasciotomy. Heat worsens swelling, elevation helps but is not enough, and toe movement doesn't address the urgency.
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The nurse is teaching a new grad about contractures. The nurse knows which statement about contractures secondary to immobility is accurate?
- A. Contractures cannot be prevented because of muscular spasticity.
- B. Contractures cannot be prevented because of muscular tension.
- C. Flexion contractures are the least commonly occurring contracture.
- D. Flexion contractures are the most commonly occurring contracture.
Correct Answer: D
Rationale: Flexion contractures are the most common due to immobility, as muscles shorten in a flexed position. Contractures can be prevented with range of motion and positioning, despite spasticity or tension.
A client sustained a right leg fracture after an industrial accident and reports tingling and severe pain inside the newly applied plaster cast. Upon inspection, the nurse noted that the exposed toes were cyanotic. What is the most appropriate nursing intervention?
- A. Apply heat packs on the leg
- B. Elevate the affected extremity
- C. Contact the physician immediately
- D. Instruct the client to move or wiggle their toes
Correct Answer: C
Rationale: Tingling, severe pain, and cyanotic toes suggest compartment syndrome, a medical emergency. Contacting the physician immediately is critical for evaluation and possible intervention like cast removal or fasciotomy. Heat worsens swelling, elevation helps but is not enough, and toe movement doesn't address the urgency.
While training a new RN in the emergency department, the nurse attends to a client with Guillain-Barre Syndrome. The new RN asks what may have caused this condition. Which of the following occurrences in the patient's history is most likely a contributing factor?
- A. A spinal cord injury at age 12
- B. An upper respiratory infection about a month ago
- C. Hydrocephaly as an infant
- D. A joint injury as a teenager
Correct Answer: B
Rationale: Guillain-Barre Syndrome is often triggered by a recent infection, commonly an upper respiratory infection, leading to an autoimmune response against peripheral nerves. Spinal cord injury, hydrocephaly, and joint injury are unrelated.
While reviewing a client's medical record who has fallen twice in the past month, which medications should the nurse recommend be discontinued to lower the client's risk for future falls?
- A. Fluoxetine
- B. Temazepam
- C. Bupropion
- D. Ferrous sulfate
- E. Hydrocodone-acetaminophen
- F. Hydroxyzine
- G. Docusate
Correct Answer: B, E, F
Rationale: Temazepam (sedative), hydrocodone-acetaminophen (opioid), and hydroxyzine (sedating antihistamine) increase fall risk via drowsiness or dizziness. Fluoxetine, bupropion, ferrous sulfate, and docusate have lower fall risk.
The nurse educates a client about the application of a plaster cast to a fractured radius. Which of the following statements by the client would require follow-up?
- A. If my arm feels itchy, I can use a hair dryer on the cool setting for relief.'
- B. I can reduce my arm's swelling by elevating it with a pillow.'
- C. I should be okay to shower with my cast.'
- D. It will be normal for me to feel heat after the cast is applied.'
Correct Answer: C
Rationale: Showering with a plaster cast risks wetting it, leading to breakdown or infection, requiring follow-up. Cool air for itching, elevation for swelling, and initial heat from cast setting are appropriate.