Exam review 1 (H&I II)

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

Incontinence; inability to move independently

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

Increase residue in the diet

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

Suprapubic distention

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

The injury is above the sixth thoracic vertebra

The nurse is caring for a client with a fractured hip. Which is the nurse trying to prevent by placing pillows around the injured area?

abduction

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

applying cold compresses, elevating the extremity above heart level

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

compartment syndrome

When teaching a health awareness class, which situation would the nurse teach as being the highest risk factor for the development of a deep vein thrombosis?

inactivity

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?

left leg is noticeably shorter than the right

Which condition would the nurse suspect in an emergency department client with C8 tetraplegia, blood pressure of 80/40 mm Hg, pulse of 48 beat per minute, and respiratory rate (RR) of 18 breaths per minute?

neurogenic shock

Which findings would support a clients diagnosis of parkinson disease?

non-intentional tremors, masklike facial expression, rigidity to passive movement

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

perform a neurovascular assessment of the lower extremities

Which nursing action would be a priority for a client with a spinal cord injury who has developed sudden autonomic dysreflexia?

place in a sitting position

The nurse is caring for a child who has an external fixation device on the leg. Which is the nurses priority goal when providing 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 spasm and pain

Which mechanism of action would the nurse identify for levodopa therapy prescribed to a client diagnosed with parkinson disease?

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

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

turn and reposition the client every 2 hours

What stage is full thickness loss in tissue with the base of the ulcer covered with slough?

unstageable pressure injury