Which of the following symptoms should the nurse specifically monitor while assessing a client with a femoral neck fracture?

Correct Answer: A

Rationale: The correct answer is A) Severe pain at the site of the fracture. When assessing a client with a femoral neck fracture, monitoring for severe pain is crucial because it is a typical symptom associated with this type of injury. Femoral neck fractures can cause intense pain in the hip or groin area, which can be exacerbated by movement or weight-bearing. This symptom is indicative of the severity of the injury and can also help in determining the need for immediate medical intervention to manage pain and prevent complications like immobility or further damage. Option B) Bleeding from joint capsules is not typically a common symptom associated with a femoral neck fracture. While there may be internal bleeding associated with the fracture, it is not usually visible externally as bleeding from joint capsules. Option C) Muscle spasms are not specific to femoral neck fractures and can occur due to various reasons such as muscle strain or nerve irritation. While muscle spasms can be a response to pain, they are not unique to this type of fracture. Option D) Crepitus at the site of the fracture, which refers to a grating or grinding sensation or sound with movement, is more commonly associated with conditions like osteoarthritis or joint injuries involving cartilage damage. It is not a typical finding in femoral neck fractures. Educationally, understanding the specific symptoms associated with different types of fractures is crucial for nurses to accurately assess and provide appropriate care to clients. Recognizing the key signs of a femoral neck fracture, such as severe pain, enables prompt intervention and can help prevent complications and promote better outcomes for the patient.

Correct Answer: C

Rationale: In the context of a patient with osteomyelitis, a serious infection of the bone, the most critical vital sign to monitor closely is the heart rate. Osteomyelitis can lead to systemic inflammatory responses in the body, causing an increase in heart rate as the body tries to fight off the infection. A heart rate of 96 beats per minute indicates tachycardia, which can be a sign of the body's stress response to the infection. This rapid heart rate may indicate systemic involvement and the potential for worsening sepsis, requiring immediate attention and intervention. The other vital signs provided in the options are also important in assessing a patient's condition, but they are not as directly linked to the urgency of osteomyelitis as heart rate. A temperature of 99.9°F may indicate a slight fever, which is common in infections but may not be as acutely concerning as an elevated heart rate in this context. The blood pressure and respiratory rate provided fall within normal ranges and do not necessarily indicate an immediate need for intervention in a patient with osteomyelitis. In an educational context, understanding the significance of vital signs in different clinical scenarios is crucial for healthcare providers to prioritize and respond to patient needs effectively. Teaching students to recognize the specific implications of vital signs in conditions like osteomyelitis helps develop their clinical reasoning skills and enhances their ability to provide timely and appropriate care to patients in various healthcare settings.

Correct Answer: C

Rationale: In the context of assessing the contraindications for an MRI scan, the correct answer is option C - Clients with metal implants in their body. MRI uses powerful magnets to create detailed images of the body, and metal objects can be strongly attracted to the magnet, causing serious harm to the individual and interfering with the imaging process. Option A - Overweight clients, and option B - Clients over the age of 60, are not contraindications for MRI scans. MRI is a safe imaging modality for individuals of various weights and ages. Option D - Clients with brain tumors, would actually be a population that would benefit from an MRI scan as it is a useful tool in diagnosing and monitoring brain tumors. Educationally, it is essential for healthcare providers to understand the safety considerations and contraindications related to different diagnostic procedures like MRI scans to ensure the well-being of their patients and the accuracy of diagnostic results. This knowledge helps in making informed decisions about the appropriate diagnostic tests based on the individual's specific health conditions.

Correct Answer: A

Rationale: The correct answer is A) Turn the client every 2 hours to prevent skin breakdown. This is essential in the nursing management of a client with Guillain-Barré syndrome who is immobile. Turning the client frequently helps in preventing pressure ulcers, which can develop due to prolonged immobility. Option B) Range-of-motion (ROM) exercises every 8 hours is not the priority in this situation. While ROM exercises are important for maintaining joint mobility and preventing contractures, preventing skin breakdown takes precedence in an immobile client to avoid serious complications. Option C) Encouraging the client to participate in self-care may not be feasible in a client with Guillain-Barré syndrome who is immobile due to the severity of the condition. The focus should be on providing necessary care and support to meet the client's needs. Option D) Consulting with a physical or occupational therapist on independence activities is important in the rehabilitation phase of Guillain-Barré syndrome when the client starts to regain mobility. However, in the acute phase when the client is immobile, the priority is to prevent complications like skin breakdown. In an educational context, understanding the priorities in nursing care for clients with neurological conditions like Guillain-Barré syndrome is crucial for providing safe and effective care. Nurses need to prioritize interventions based on the client's condition and immediate needs to prevent complications and promote recovery.

Correct Answer: A

Rationale: Rationale: The correct answer is A) Measure intake and output. Monitoring intake and output is crucial in assessing electrolyte imbalances and dehydration in clients with neurologic deficits. Neurologic conditions can impact the body's ability to regulate fluid and electrolyte balance, making these clients more susceptible to imbalances. Option B) Use the Glasgow Coma Scale is incorrect as it is a tool used to assess a patient's level of consciousness and is not directly related to monitoring for electrolyte imbalances or dehydration. Option C) Mini-Mental Status Examination is a cognitive assessment tool used to evaluate cognitive function and is not specific to monitoring fluid and electrolyte status in clients with neurologic deficits. Option D) Assess vital signs is important in the overall assessment of a client, but it may not provide specific information about electrolyte imbalances and dehydration unless significant changes are already present. Educational Context: Nurses caring for clients with neurologic deficits need to have a comprehensive understanding of how these conditions can impact the body's homeostasis, including fluid and electrolyte balance. Monitoring intake and output is a fundamental nursing skill that helps in early detection of imbalances, allowing for prompt interventions to prevent complications. Understanding the rationale behind each assessment helps nurses provide holistic care to their clients and enhance patient outcomes.