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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Explanation
Choice A rationale: The lab results and clinical picture, such as weight loss, anorexia, and high blood glucose levels, point more toward a hyperglycemic state rather than severe hypoglycemia.
Choice B rationale: The client's elevated blood glucose levels, weight loss, and anorexia suggest a hyperglycemic state, possibly hyperosmolar hyperglycemic state, which requires fluid management and insulin to address the severe dehydration and high blood glucose levels.
Choice C rationale: Although high glucose levels are evident, the absence of significant acidosis (as seen in diabetic ketoacidosis) and extreme ketosis makes this diagnosis less likely.
Choice D rationale: The lab values and clinical presentation do not strongly align with a primary respiratory acidosis diagnosis, which typically involves changes in pH and carbon dioxide levels.
Correct Answer is D
Explanation
Choice A rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
Choice B rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
Choice C rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
Choice D rationale: Serosanguineous nasal drainage (a mixture of blood and clear fluid) may suggest a basilar skull fracture, which is a fracture of the base of the skull that can damage vital structures such as the brainstem, cranial nerves, or major blood vessels. This can lead to serious complications such as meningitis, cerebrospinal fluid leak, or hemorrhage.
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