A 16-year-old male presents to the emergency department with right knee pain.
Complete the statement below:
The client is at risk for and the nurse should ?
Fracture/immobilized the extremity
Contracture / obtain a prescription for acetaminophen
Sprain/ raise the leg
Dislocation/apply heat to the area
The Correct Answer is A
Choice A rationale: Considering the mechanism of injury, pain severity, tenderness, swelling, and ecchymosis, there is a high suspicion of a fracture. Immobilization is essential to prevent further injury and reduce pain.
Choice B rationale: Contracture is less likely in this acute injury scenario. Acetaminophen might manage pain, but it doesn't address the risk factor.
Choice C rationale: A sprain is less likely given the severity of pain and the mechanism of injury. Raising the leg doesn't address the risk of a suspected fracture.
Choice D rationale: Dislocation doesn't align with the reported symptoms. Applying heat could potentially worsen inflammation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Assessing the UOP is important, but not as urgent as correcting the potassium imbalance.
Choice B rationale: Obtaining a 12-lead ECG can help monitor the cardiac status, but it does not address the cause of the problem.
Choice C rationale: The PMHCP can order potassium replacement to prevent cardiac arrhythmias and other adverse effects of low potassium levels.
Choice D rationale: Stopping the regular insulin infusion can worsen the DKA and increase the risk of cerebral edema and coma.
Correct Answer is A
Explanation
Choice A rationale: The signs and symptoms of urinary catheter obstruction include hematuria with clots, bladder spasms, and a feeling of urinary urgency. The nurse should increase the rate of the continuous bladder irrigation to flush out the clots and relieve the obstruction. The nurse should also monitor the client's vital signs, fluid balance, and pain level. The other options are not consistent with the client's presentation.
Choice B rationale: Shock would cause hypotension, tachycardia, and decreased urine output.
Choice C rationale: Hyponatremia would cause confusion, weakness, and seizures.
Choice D rationale: Urinary tract infection would cause fever, chills, and foul-smelling urine.
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