the nurse is assessing a client who had a cast placed 4 hours ago what assessment finding is cause for concern

ATI RN

Multi Dimensional Care | Final Exam

1. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?

A. The nurse assesses capillary refill of 2 seconds
B. The nurse cannot insert one finger between the cast and the skin
C. The nurse finds 2+ pulses distal from the cast
D. The nurse does not observe any drainage

Correct answer: B

Rationale: Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.

2. Why is a client with osteoporosis prone to fractures?

A. The client has bone spurs that lead to fractures
B. The client has increased bone density
C. The client has porous bones
D. The client is not prone to fractures

Correct answer: C

Rationale: The correct answer is C. Osteoporosis is characterized by porous, weak bones due to decreased bone density. This porous nature of bones in osteoporosis makes them more prone to fractures. Choice A is incorrect because bone spurs do not lead to fractures in osteoporosis; they are bony outgrowths unrelated to osteoporosis. Choice B is incorrect as osteoporosis is associated with decreased, not increased, bone density. Choice D is incorrect as individuals with osteoporosis are indeed prone to fractures due to weakened bones.

3. The nurse educates a client about how to reduce their risk for osteoporosis. Which of these statements by the nurse is correct? (Select all that apply)

A. You can decrease your risk of osteoporosis by avoiding vitamin D.
B. You can decrease your risk of osteoporosis by reducing caffeine intake.
C. You can decrease the risk of osteoporosis by decreasing alcohol intake.
D. You can decrease your risk of osteoporosis by reducing protein intake.

Correct answer: B

Rationale: Reducing caffeine and alcohol intake, and quitting smoking can help decrease the risk of osteoporosis.

4. What is the priority nursing diagnosis after surgery to repair a fracture?

A. Disturbed body image
B. Risk for infection
C. Risk for impaired skin integrity
D. Acute pain

Correct answer: B

Rationale: The correct answer is B: Risk for infection. After surgery to repair a fracture, the priority nursing diagnosis is to monitor for the risk of infection to promote proper healing. Infections can significantly delay the healing process and lead to further complications. Choices A, C, and D are not the priority immediately post-surgery. Disturbed body image, risk for impaired skin integrity, and acute pain may be concerns but are not the priority in the immediate post-operative period following fracture repair.