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 A
Explanation
Choice A rationale: This patient is likely experiencing hyperosmolar hyperglycemic state (HHS). Rapid administration of IV fluids is crucial to correct severe dehydration associated with HHS.
Choice B rationale: Routine insulin therapy and exercise might be components of diabetes management but wouldn't directly address the immediate concern of severe dehydration and high blood glucose.
Choice C rationale: Cardiac monitoring for potassium changes might be necessary but isn't the primary immediate intervention for HHS.
Choice D rationale: Administering a different antibiotic for the UTI is incorrect, because there is no evidence that the current antibiotic is ineffective or causing adverse effects. The UTI may have triggered the HHS, but it is not the main problem that needs to be addressed urgently.
Correct Answer is B
Explanation
Choice A rationale: Anterior spinal artery syndrome is caused by ischemia of the anterior two-thirds of the spinal cord, resulting in loss of motor function and pain and temperature sensation below the level of the lesion.
Choice B rationale: This is a condition that occurs when the nerve roots in the lower end of the spinal cord are compressed, causing symptoms such as lower back pain, sciatica, saddle anesthesia, bladder and bowel dysfunction, and sexual dysfunction.
Choice C rationale: Horner's syndrome is caused by damage to the sympathetic nerve fibers in the neck or chest, resulting in drooping eyelid, constricted pupil, and lack of sweating on one side of the face.
Choice D rationale: Brown-Séquard syndrome is caused by hemisection of the spinal cord, resulting in ipsilateral loss of motor function and proprioception and contralateral loss of pain and temperature sensation below the level of the lesion.
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