A nurse is assisting with the care of a client on an orthopedic unit.
Select words from the choices below to fill in each blank in the following sentence.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"C"}
The correct answer is choice A: Fat embolism syndrome.
Choice A rationale:
The client with an open fracture to the right femur is at risk for developing Fat Embolism Syndrome (FES) FES occurs when fat globules from the bone marrow or other tissues enter the bloodstream, leading to systemic complications. In this case, with an open fracture, there is a higher risk of fat emboli entering the circulation. The clinical manifestations of FES include respiratory distress, altered mental status, and petechial rash. These symptoms typically occur within 24-72 hours after the injury, which aligns with the timeline mentioned in the progress report on Day 1 of admission.
Choice B rationale:
Osteomyelitis is less likely to develop within the first 24 hours following a motor vehicle crash. It is an infection of the bone and typically takes more time to manifest. The early concerns in an open fracture involve the risk of infection, but osteomyelitis is not an immediate threat in this scenario.
Choice C rationale:
Compartment syndrome is a potential concern in orthopedic injuries, but it primarily arises due to increased pressure within a muscle compartment, causing reduced blood flow. While it is a valid concern, it is not typically associated with fat embolism syndrome, which is more specific to the release of fat globules into the bloodstream.
Choice D rationale:
Deep vein thrombosis (DVT) is a concern in immobile patients or those with significant trauma, but it is not the most immediate concern in this case. DVT usually develops over time and is more associated with prolonged immobilization rather than the early stages of admission.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: Quoting client comments when documenting provides accurate and direct information. It ensures the client's exact words are recorded, which is important for clear communication among healthcare providers and for legal documentation.
Choice B rationale: Documenting medication administration should occur immediately after giving the dose, not prior. This ensures accuracy and prevents potential errors or omissions, maintaining the integrity and safety of the client's medical record.
Choice C rationale: Documenting information telephoned in by a nurse who left the unit ensures continuity of care. It accurately records details that may be critical to the client's treatment and care plan, ensuring that all healthcare providers have up-to-date information.
Choice D rationale: Limiting documentation to subjective information is not sufficient. Comprehensive documentation should include both subjective (client's statements) and objective (measurable data) information to provide a complete and accurate picture of the client's condition and care.
Correct Answer is D
Explanation
Choice A rationale:
Decreased skin turgor. Decreased skin turgor is a sign of dehydration rather than fluid overload. In fluid overload, the body retains excess fluid, leading to symptoms like crackles in the lungs, edema, and increased blood pressure. Decreased skin turgor is more characteristic of dehydration, where the body loses fluid.
Choice B rationale:
Decreased blood pressure. Decreased blood pressure is not typically a manifestation of fluid overload. Fluid overload often leads to increased blood pressure as the heart has to work harder to pump excess fluid throughout the body.
Choice C rationale:
Weight loss. Weight loss is not a manifestation of fluid overload. In fact, fluid overload may lead to weight gain due to the retention of excess fluid in the body.
Choice D rationale:
Crackles heard in the lungs. Crackles heard in the lungs are a common manifestation of fluid overload. When there is an excessive accumulation of fluid in the lungs, it can interfere with the exchange of gases and cause crackling sounds during breathing. This is a significant clinical finding that indicates the need for intervention and assessment of fluid balance.
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