A nurse is assisting with the care of a client.
Vital Signs.
1330: Temperature 36.8 °C (98.2 °F) Heart rate 88/min.
Respiratory rate 16/min.
Blood pressure 110/64 mm Hg. 1345: Oxygen saturation 96% on 3 L/min via simple face mask.
Temperature 37 °C (98.6 °F) Heart rate 112/min.
Respiratory rate 20/min.
Blood pressure 108/60 mm Hg. 1400: Oxygen saturation 94% on 3 L/min via simple face mask.
Temperature 38.3 °C (101 °F) Heart rate 152/min.
For each data collection finding, click to specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock.
Each finding may support more than 1 disease process.
Wheezes
Muscle rigidity
Urticaria
Hypercapnia
Tachycardia
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A,B,C"}}
Wheezes: This finding may indicate a latex allergy, as wheezing is a sign of respiratory distress caused by an allergic reaction to latex proteins. Wheezes are not typical of malignant hyperthermia or hypovolemic shock.
Muscle rigidity: This finding is a hallmark of malignant hyperthermia, as it reflects the excessive calcium release and muscle contraction triggered by certain anesthetic agents. Muscle rigidity is not a feature of latex allergy or hypovolemic shock.
Urticaria: This finding is a common manifestation of latex allergy, as urticaria (hives) is a type of skin rash caused by an allergic reaction to latex proteins. Urticaria is not associated with malignant hyperthermia or hypovolemic shock.
Hypercapnia: This finding is indicative of malignant hyperthermia, as hypercapnia (high carbon dioxide levels in the blood) is a result of increased metabolism and oxygen consumption due to muscle rigidity and fever. Hypercapnia is not usually seen in latex allergy or hypovolemic shock, unless there is severe respiratory compromise.
Tachycardia: This finding can be present in all three disease processes, as tachycardia (fast heart rate) is a nonspecific response to stress, fever, pain, hypoxia, or hypovolemia. However, tachycardia is more pronounced and persistent in malignant hyperthermia and hypovolemic shock than in latex allergy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Evaluating the client for signs of infection is an important nursing action in post-procedure care, but it is not the priority immediately following an amniotomy. The primary concern after an amniotomy is fetal well-being, so monitoring the fetal heart rate is the priority.
Choice B rationale:
Checking the fetal heart rate pattern is the priority nursing action following an amniotomy. Amniotomy involves breaking the amniotic sac, which can potentially lead to changes in the fetal heart rate. Monitoring the fetal heart rate helps assess the baby's well-being and detects any signs of fetal distress.
Choice C rationale:
Observing the color and consistency of amniotic fluid is important for assessing the fluid for signs of meconium staining or infection, but it is not the immediate priority after an amniotomy. Checking the fetal heart rate takes precedence.
Choice D rationale:
Taking the client's temperature is an important part of assessing for infection or fever, but it is not the immediate priority following an amniotomy. Fetal well-being and monitoring are the primary concerns in the immediate post-amniotomy period.
Correct Answer is {"dropdown-group-1":"C"}
Explanation
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.
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