A nurse is performing a neurovascular assessment on a client who has just had a long leg cast applied. In addition to checking the client's extremity for pain and paresthesia, the nurse must assess for:
a. restlessness c. pulselessness
b. sleep patterns d. dietary intake
C
Neurovascular assessment on a client with a cast should include assessing pain, paresthesia, edema, and pallor; checking pulses distally; and checking skin for color and temperature.
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A client tells the nurse that she has difficulty sleeping when she has to rotate between working the day shift and the night shift. The nurse realizes that which of the following is most likely being disrupted in this client?
a. ultradian rhythm c. infradian rhythms b. circadian rhythm d. circannual rhythms
The nurse should encourage a client being treated with corticosteroids for an autoimmune disease to have frequent examinations by an ophthalmologist because corticosteroids increase the risk of:
1. muscle weakness secondary to hypokalemia. 2. glaucoma. 3. sodium and water retention. 4. bone fractures.
The nurse is caring for a patient with agina pectoris who asks what happens to make his body experience pain. The nurse explains that pain results from which underlying causative factor?
a. Congestion that backs up into the lungs b. Inadequate blood flow and poor oxygen supply c. Edema from fluid overload d. Inflammation in the vessels
At 2100, J.O.'s guard summons you to his room. J.O. is pale, slightly confused, and complaining of chest
pain and dyspnea. Vital signs are 90/60, 120, 28, 100.0° F (37.8° C), and Spo2 of 84%. His pulse is weak and thready and there are petechiae on his chest. What do you immediately expect is occurring and why?