The nurse is caring for a client who experienced a crushing injury of the lower extremities. Which of the following symptoms is essential to be reported to the physician?
A) Coolness
B) Pain
C) Pulselessness
D) Ischemia
C
Feedback:
Neurovascular checks (circulation, sensation, motion) are essential with a crushing injury. The absence of a pulse is a critical assessment finding to report to the physician. The other options are symptoms that need regular assessment.
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A nurse is with a group of children who experienced a school shooting yesterday. As the nurse interacts with the children, the goal is to:
A) Provide a safe, controlled environment to share thoughts and feelings. B) Provide opportunity for individual treatment. C) Assess for medication needs. D) Provide educational information.
It has been determined that all of the following clients are at risk for falling. Which one requires the nurse's priority for ambulation?
1. A 16-year-old with a sprained ankle being discharged from the emergency de-partment 2. A 54-year-old who has taken the initial dose of an antihypertensive medication 3. A 45-year-old postoperative client up for the first time since knee surgery 4. An 81-year-old who is asthmatic and had a hip replaced 18 months ago