Question

A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply)

Answer 1

Correct Answers:

Apply a compression bandage to the client’s ankle.
Elevate the clients foot.
Check the clients toes for color, temperature, and sensation.

Rationale :

🔹 Apply a compression bandage to the client’s ankle:

Compression helps reduce swelling by limiting the accumulation of fluid in the interstitial tissues.
It provides support to the injured joint and promotes stability, which is essential during the acute phase of soft tissue injury.
Proper compression also minimizes further tissue damage and supports venous return.

🔹 Elevate the client’s foot:

Elevation promotes venous and lymphatic drainage, reducing edema and pain.
Raising the limb above heart level decreases hydrostatic pressure in the capillaries, which slows fluid accumulation in the injured area.
This is particularly important during the first 24 to 48 hours post-injury.

🔹Check the client’s toes for color, temperature, and sensation:

Neurovascular assessment is critical in injuries involving swelling or compression.
Evaluating circulation (color and temperature), sensation, and movement (CSM) ensures that blood flow is intact and that no nerve damage or compartment syndrome is developing beneath the swelling or bandage.

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Answer 2

Correct Answers:

Infection

Rationale :

➤ A warm spot on a cast is a key clinical sign of infection, especially if accompanied by odor, discharge, or localized pain.

➤ The cast can trap moisture and create a warm, dark environment ideal for bacterial growth.

➤ Infection under a cast is a medical emergency because it can lead to osteomyelitis or systemic infection if left unrecognized.

➤ The warmth from uneven cast drying typically occurs in the early hours after cast application and is generalized—not localized.

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Answer 3

Correct Answers:

Boutonniere deformity

Rationale :

➤ Boutonniere deformity involves flexion of the PIP (proximal interphalangeal) joint and hyperextension of the DIP (distal interphalangeal) joint.

➤ It is a classic musculoskeletal abnormality in rheumatoid arthritis, resulting from synovial inflammation that weakens tendons.

➤ This chronic autoimmune condition affects joints symmetrically and progressively, particularly in the fingers and hands.

➤ Tophi are indicative of gout; Heberden’s nodes are signs of osteoarthritis; osteoma is a benign bone tumor—not associated with RA.

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Answer 4

Correct Answers:

The client can follow simple motor commands.

Rationale :

✍️ A GCS score is calculated as:

▪ Eye opening = 3 (to verbal command)

▪ Verbal = 5 (oriented and converses normally)

▪ Motor = 5 (localizes pain or follows simple commands)

✍️ Total score = 13, indicating mild brain injury, not unconsciousness.

✍️ Since the motor response is 5, the client can follow commands, which helps assess neurological function.

✍️ Eye opening to voice (not spontaneously) also supports the conclusion that the client is responsive and aware.

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Answer 5

Correct Answers:

Place a wedge pillow between the legs.

Rationale :

➤ After total hip arthroplasty, it’s vital to maintain hip abduction to prevent dislocation of the prosthetic joint.

➤ A wedge pillow (abduction pillow) ensures the legs stay properly aligned and avoids movements that could lead to dislocation (e.g., internal rotation, adduction).

➤ Trochanter rolls, sandbags, and footboards do not effectively prevent adduction and are not reliable for maintaining hip positioning postoperatively.

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Answer 6

Correct Answers:

Abduction

Rationale :

✍️ After hip surgery, placing the leg in abduction keeps the femoral head in the acetabular socket, minimizing the risk of dislocation.

✍️ Internal or external rotation can strain the healing tissues and prosthesis, increasing risk of injury.

✍️ This position is often maintained with an abduction wedge or pillow, especially in the first few postoperative days.

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Answer 7

Correct Answers:

Check the client for injuries.

Rationale :

✅ Immediate assessment is critical to identify injuries such as fractures, bleeding, or head trauma.

✅The nurse should perform a head-to-toe assessment before moving the client to avoid exacerbating potential injuries.

✅ Applying restraints or sedatives is inappropriate without a medical indication and assessment.

✅Family involvement and support follow after clinical evaluation is completed.

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Answer 8

Correct Answers:

Call emergency medical services.

Rationale :

➡️ These signs are classic for a stroke (CVA)—slurred speech, one-sided weakness, and sudden collapse.

➡️ Time is critical in stroke care; calling EMS ensures rapid transport to a stroke center where treatment can begin immediately.

➡️Delaying care to call a provider or drive the client to the hospital can worsen outcomes.

➡️ The nurse must act immediately to initiate the chain of survival.

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Answer 9

Correct Answers:

Developing a respiratory infection

Rationale :

✳️ Myasthenic crisis is an acute exacerbation of myasthenia gravis resulting in severe muscle weakness, including respiratory muscles.

✳️ Infections (especially respiratory) are the most common trigger, as they increase metabolic demand and immune response.

✳️This condition may require mechanical ventilation if respiratory muscles become too weak.

✳️ Overmedication typically causes cholinergic crisis, not myasthenic crisis.

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Answer 10

Correct Answers:

Small drops of clear fluid in the left ear

Rationale :

🍃 Clear fluid from the ear after head trauma can indicate cerebrospinal fluid (CSF) leakage, a sign of basilar skull fracture.

🍃 This is a neurological emergency requiring immediate attention and potential surgical intervention.

🍃 Other findings (e.g., disorientation, bruising) are important but not as urgently life-threatening as a CSF leak.

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QLexNursing

1 :
A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply)

2 :
While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following findings should the nurse identify as a complication to the client's condition?

3 :
A nurse is collecting data from a client who has rheumatoid arthritis. Which of the following is an expected finding for this client?

4 :
A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye-opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

5 :
A nurse is assisting a client who is postoperative following a total hip arthroplasty into a supine position. Which of the following actions is appropriate to prevent hip dislocation?

6 :
A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the client's right leg?

7 :
A nurse in a long-term care facility finds an older adult client lying on the floor next to the bed. Which of the following actions should the nurse take?

8 :
A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following actions should the nurse take?

9 :
A nurse in the emergency department is assisting with the care of a client who has myasthenia gravis and is in crisis. The nurse should identify which of the following factors can cause a myasthenic crisis.

10 :
A nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?

QLexNursing

1 : A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply)

2 : While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following findings should the nurse identify as a complication to the client's condition?

3 : A nurse is collecting data from a client who has rheumatoid arthritis. Which of the following is an expected finding for this client?

4 : A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye-opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

5 : A nurse is assisting a client who is postoperative following a total hip arthroplasty into a supine position. Which of the following actions is appropriate to prevent hip dislocation?

6 : A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the client's right leg?

7 : A nurse in a long-term care facility finds an older adult client lying on the floor next to the bed. Which of the following actions should the nurse take?

8 : A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following actions should the nurse take?

9 : A nurse in the emergency department is assisting with the care of a client who has myasthenia gravis and is in crisis. The nurse should identify which of the following factors can cause a myasthenic crisis.

10 : A nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?

1 :
A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply)

2 :
While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following findings should the nurse identify as a complication to the client's condition?

3 :
A nurse is collecting data from a client who has rheumatoid arthritis. Which of the following is an expected finding for this client?

4 :
A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye-opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

5 :
A nurse is assisting a client who is postoperative following a total hip arthroplasty into a supine position. Which of the following actions is appropriate to prevent hip dislocation?

6 :
A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the client's right leg?

7 :
A nurse in a long-term care facility finds an older adult client lying on the floor next to the bed. Which of the following actions should the nurse take?

8 :
A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following actions should the nurse take?

9 :
A nurse in the emergency department is assisting with the care of a client who has myasthenia gravis and is in crisis. The nurse should identify which of the following factors can cause a myasthenic crisis.

10 :
A nurse is collecting data from a client who fell at home and reported a brief loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?