A nurse is assisting in the care of a client in the intensive care unit (ICU)

Exhibits

The nurse should identify which of the following client's conditions can indicate the development of delirium.

Rationale:
• Compartment syndrome: Casts can restrict swelling, increasing pressure within the compartment. Moderate toe edema and capillary refill slowing from brisk to 3 seconds are warning signs. Without prompt intervention, tissue perfusion may decline, leading to ischemia.

• Edema of toes: Progressive edema signals impaired venous return or rising intracompartmental pressure. It reflects worsening limb status under the cast. This change, with slowed refill, supports risk for compartment syndrome.

• Malunion: Malunion develops over weeks due to misalignment during healing. No imaging or prolonged healing time is reported. Acute symptoms like swelling and pain don’t indicate this long-term issue.

• Physeal damage: Growth plate injury would affect long-term limb development. The adolescent shows intact toe movement and normal limb function otherwise. No evidence of joint or bone disruption is presented.

• Inability to ambulate: The femur fracture and cast already restrict ambulation. Lack of walking is expected at this stage. It doesn't suggest any specific complication like infection or compartment syndrome.

• Infection: Fever is low-grade and expected post-injury or from opioids. No redness, drainage, or systemic illness is present. Pain is stable and localized, not escalating or spreading.

• Decreased dorsalis pedis pulse: Pulses are 2+, meaning circulation is present and adequate. Decreased or absent pulse would indicate severe compromise, but that is not seen here. It does not reflect early compartment syndrome.

Rationale:

A. "You should replace your diaphragm every 2 years": Diaphragms generally need to be replaced every 1 to 2 years, depending on the manufacturer’s guidelines and wear and tear. However, it is more important to be aware of refitting needs related to physiological changes.

B. "You should be refitted for your diaphragm if you have a 10 percent weight fluctuation.": Significant weight changes, usually around 10 to 15 percent, can alter pelvic anatomy and affect diaphragm fit, increasing the risk of contraceptive failure. Therefore, refitting is recommended after notable weight fluctuations.

C. "You should insert the diaphragm when your bladder is full.": The bladder should be empty when inserting the diaphragm to avoid discomfort and ensure proper placement over the cervix. A full bladder can cause displacement and increase the risk of failure.

D. "You should remove your diaphragm 4 hours after intercourse.": The diaphragm should be left in place for at least 6 hours after intercourse to ensure adequate sperm immobilization and contraceptive effectiveness. Removing it too early may increase the risk of pregnancy.