H&I II: Exam 1 EAQ

Which client with complications of fracture would the nurse expect may be treated with a fasciotomy?

A client with compartment syndrome

Which client has an unstageable pressure injury?

Client B- full-thickness loss in tissue with the base of the ulcer covered by slough

Which findings would support a client's diagnosis of PD? Select all that apply

Nonintentional tremors masklike facial expression rigidity to passive movement

Which nursing intervention would be contraindication for a client who has a fracture and has compartment syndrome?

Applying a cold compress Elevating the extremity about the heart level

Which rationale explains why the nurse would monitor a client who has a spinal cord injury at the T2 level for signs of autonomic dysreflexia?

B. ) The injury is above the sixth thoracic vertebra WHich Rationale: The T6 level is the sympathetic visceral outflow level. Because the client's injury is above this level (T2), autonomic hyperreflexia is expected. The reflex arc remains intact after spinal cord injury. The important point is not that the cord is transected, but the level at which the injury occurred. A flaccid paralysis of the lower extremities is not related to autonomic hyperreflexia. All cord injuries result in flaccid paralysis during the period of spinal shock; as the inflammation subsides, spasticity gradually increases.

When the chest x-ray of a client who arrived at the emergency department with chest trauma shows multiple fractured ribs, which action would the nurse take next?

Check for paradoxical movement of the chest wall

Which position would the nurse use for placement of the affected extremity of a client who is recovering from an open reduction and internal fixation (ORIF) of a fractured hip?

Moderate abduction

Which signs of compartment syndrome would the nurse assess for in the client who has sustained blunt trauma to the forearm?

Escalating pain in the fingers

Which clinical manifestation would the nurse expect to identify in a client experiencing spinal shock immediately after sustaining a functional transection of the spinal card at C7-C8? Select all that apply.

Flaccid paralysis Lack of reflexes below the injury

Which combination of client Reponses would the nurse determine represents the highest risk for the development of pressure injuries?

Incontinence; inability to move independently

A client with Parkinson's disease reports problems with bowel elimination. Which instruction should the nurse provide the clients?

Increase residue in the diet

Which action would the nurse take in caring for a client after surgical placement of an external fixator on the clients leg?

Perform a neurovascular assessment of the lower extremities. - A neurovascular assessment identifies early signs and symptoms of compartment syndrome. Compartment syndrome is increased pressure within a closed fascial space caused by a fracture or soft-tissue damage that compresses circulatory vessels, nerves, and tissues, compromising viability of the limb. The nurse would monitor for the six Ps: unrelenting pain, pallor, paresthesia, pressure, pulselessness, and paralysis. In addition, the circumference of the extremity will increase, and the leg will feel hard and firm on palpation. Both legs are assessed for symmetry. There is no established standard of care associated with pin care; some primary health care providers believe that pin care is contraindicated because it disrupts the skin's natural barrier to infection. Initially the client should use a wheelchair or walk without bearing weight on the affected extremity. As healing occurs, the primary health care provider will prescribe progressive weight bearing exercises. Maintaining abduction of the leg is not necessary with an external fixation of the tibia.

Which nursing intervention would be most appropriate when caring for an acutely agitated client diagnosed with paranoid schizophrenia? A. Provide neon lights and soft music. B. Maintain continual eye contact throughout the interview. C. Use therapeutic touch to increase trust and rapport. D. Provide personal space to respect the client's boundaries.

Place in sitting position

The nurse is caring for a kid with an external fixation device on the leg. Which is the nurses priority goal when giving pin care?

Preventing infection

A client with a fractured hip is placed in traction until surgery can be performed. Which goal would the nurse explain as the purpose of the traction?

Relieving muscle spasms and pain

Which mechanisms of action would the nurse identify for levodopa therapy prescribed to a client diagnosed with PD?

Restores the dopamine levels in the brain

Which stage would the nurse document for a client with a pressure injury that has exposed bone and tendons?

Stage IV

A client with a cervical injury reports the sudden onset of a severe headache and nasal congestion. For which manifestations would the nurse assess?

Suprapubic distension

The nurse is completing an assessment on an older adult who fell and fractured the left hip. Which clinical indicator would the nurse identify as typical with a fractured left hip?

The left leg is shorter than the right

Which action would the nurse take initially after discovering a client has a stage 1 pressure ulcer upon admission?

Turn and reposition every 2 hours