A physician is discussing the care of the client with a certain type of fracture with the nurse. Which type of fracture is defined as a fracture in which damage also involves the skin or mucous membranes?

Correct Answer: D

Rationale: The correct answer is D) Compound. A compound fracture, also known as an open fracture, is defined as a fracture in which damage not only involves the bone but also the skin or mucous membranes. This type of fracture poses a higher risk of infection due to the exposure of the internal tissues to the external environment. Option A) Pathologic fractures are caused by an underlying disease weakening the bone, not necessarily involving damage to the skin or mucous membranes. Option B) Compression fractures occur when bone is crushed or collapses, typically seen in conditions like osteoporosis, without necessarily involving damage to the skin. Option C) Depressed fractures involve a portion of the skull being pushed inwards, commonly seen in head injuries, and do not necessarily involve damage to the skin or mucous membranes. In an educational context, understanding the different types of fractures is crucial for healthcare professionals to provide appropriate care and treatment. Knowledge of compound fractures is essential due to the increased risk of complications such as infection, which can impact the overall management and outcomes for the patient. It is important for nurses and healthcare providers to quickly recognize and appropriately respond to compound fractures to prevent further complications and promote optimal healing.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) The patient appears confused. This finding should be reported immediately for a patient with a fractured femur because confusion can be indicative of a serious complication such as fat embolism, hypoxia, or other neurological issues that may pose a threat to the patient's well-being. Option A, the patient complaining of pain, is important but may not necessarily require immediate reporting as pain is an expected symptom of a fractured femur and is usually managed with pain medications. Option C, the patient's blood pressure being 136/88, while slightly elevated, is not a critical finding that requires immediate attention in this context. Option D, the patient voiding using the bedpan, is a normal physiological function and does not warrant immediate reporting unless there are specific concerns related to urinary retention or other issues. Educationally, it is crucial for healthcare professionals to prioritize and recognize urgent signs and symptoms in patients with fractures, especially femur fractures which can lead to serious complications. Understanding the significance of neurological changes like confusion can help prevent adverse outcomes and improve patient care. This question highlights the importance of critical thinking and quick decision-making in healthcare settings.

Correct Answer: A

Rationale: The correct answer to the question is A) Inform the physician. In the context of a sudden change in a client's vital signs, it is crucial for the nurse to promptly notify the physician. This action is essential because sudden changes in vital signs can indicate a medical emergency or a deterioration in the client's condition that requires immediate attention from a healthcare provider with the authority to make clinical decisions and order appropriate interventions. Option B) Change the environmental settings of the client is incorrect because adjusting the environmental settings would not address the underlying cause of the sudden change in vital signs. Option C) Alter the diet intake of the client is also incorrect as nutritional changes are unlikely to address acute changes in vital signs. Option D) Decrease the physical activity of the client is incorrect as it does not address the urgent need for medical assessment and intervention in response to sudden changes in vital signs. In an educational context, understanding the appropriate steps to take in response to changes in a client's vital signs is critical for nurses to ensure timely and effective care delivery. By choosing the correct answer, nurses demonstrate their ability to prioritize patient safety and advocate for the prompt assessment and management of potentially serious health concerns. This knowledge is fundamental to providing high-quality nursing care and promoting positive patient outcomes.

Correct Answer: D

Rationale: The correct answer is D) Hemorrhagic stroke. A hemorrhagic stroke occurs when a blood vessel in the brain ruptures, leading to bleeding into the brain tissue. This can result from conditions such as hypertension, aneurysms, or arteriovenous malformations. The release of blood into the brain tissue causes damage and can lead to neurological deficits. Option A) Ischemic stroke is caused by a blockage in a blood vessel, leading to a lack of blood flow and oxygen to a part of the brain. This is different from hemorrhagic stroke where there is bleeding in the brain tissue. Option B) Transient ischemic attack (TIA) is a temporary blockage of blood flow to the brain, often referred to as a "mini-stroke." It does not involve bleeding into the brain tissue like a hemorrhagic stroke. Option C) Cerebral aneurysm is a weakness in a blood vessel wall that can lead to bulging and potential rupture, causing a hemorrhagic stroke. However, the condition described in the question is specifically related to a ruptured cerebral blood vessel and blood release into the brain tissue. Educationally, understanding the differences between types of strokes is crucial for healthcare professionals, as it impacts patient assessment, treatment decisions, and outcomes. Recognizing the signs and symptoms of a hemorrhagic stroke versus an ischemic stroke is vital for timely and appropriate intervention to minimize brain damage and improve patient prognosis.

Correct Answer: D

Rationale: In this scenario, option D, "Impaired Physical Mobility related to muscle weakness and paralysis," is the correct nursing diagnosis for a client with a neurological deficit in relation to his marriage. This nursing diagnosis is appropriate because it addresses the direct impact of muscle weakness and paralysis on the individual's ability to move, which can affect their independence and ability to engage in activities essential for maintaining a healthy marriage. Option A, "Risk for Disuse Syndrome related to musculoskeletal inactivity and neuromuscular impairment," is incorrect because it focuses more on the potential consequences of inactivity rather than the current physical limitations affecting the client's mobility in the context of their marriage. Option B, "Total Urinary Incontinence or Urinary Retention related to effects of disease or injury to the nervous system or spinal cord nerves," is incorrect as it addresses urinary issues rather than the specific mobility challenges impacting the client's marriage. Option C, "loss of bladder tone," is also incorrect as it pertains specifically to bladder function and does not address the broader impact of neurological deficits on physical mobility and its implications for marital relationships. Educationally, understanding the rationale behind selecting the correct nursing diagnosis is crucial for nurses to provide targeted and holistic care to clients with neurological deficits. By choosing the most appropriate diagnosis, nurses can tailor interventions to address the specific needs of the client, promote their independence, and support their overall well-being within the context of their relationships and daily life activities.