A nurse is assisting with the care of an adolescent.
Complete the following sentence by using the lists of options.
The adolescent is at risk for developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Rationale for correct choices:
• compartment syndrome: The adolescent exhibits increasing pain despite repeated analgesia, numbness and tingling in the affected extremity, difficulty moving toes, and diminished dorsalis pedis pulse. These findings indicate compromised perfusion and rising pressure within the casted leg, consistent with the early stages of compartment syndrome, which is an orthopedic emergency requiring immediate intervention.
• decreased dorsalis pedis pulse: A decreasing dorsalis pedis pulse from 2+ to 1+, along with delayed capillary refill and edema, reflects impaired arterial blood flow distal to the cast. Monitoring pulses is critical for early detection of compartment syndrome and assessing the severity of vascular compromise in the affected limb.
Rationale for incorrect choices:
• malunion: Malunion refers to improper bone healing over time and would present weeks after fracture reduction or casting. The current acute symptoms of pain, numbness, and pulse changes are not indicative of malunion.
• physeal damage: Physeal (growth plate) injury occurs in fractures involving the epiphyseal plate and presents with growth disturbances over months. There is no specific evidence here of growth plate involvement, and the urgent neurovascular signs are more consistent with compartment syndrome.
• infection: Although increasing temperature and local edema could suggest infection, the adolescent’s acute neurovascular changes, severe pain unrelieved by morphine, and decreased pulses are more indicative of compartment syndrome rather than infection at this stage.
• inability to ambulate: The adolescent is still able to move the other extremities and previously moved the affected toes. While pain limits mobility, inability to ambulate alone is not a primary indicator of compartment syndrome.
• edema of toes: Toe edema is present but is a secondary finding and nonspecific; it supports but does not solely define compartment syndrome. Decreased pulse and pain are more critical indicators.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Urticaria: The appearance of hives (urticaria) is a classic sign of an allergic reaction to medications, including vancomycin. It reflects histamine release and immune hypersensitivity, requiring prompt assessment and possible intervention.
B. Hypertension: Vancomycin does not typically cause elevated blood pressure as an allergic response. Blood pressure changes are more likely related to underlying conditions or infusion-related hemodynamic effects, not allergy.
C. Headache: Headache is not a typical manifestation of an allergic reaction to vancomycin. It may occur as a nonspecific adverse effect but does not indicate immune-mediated hypersensitivity.
D. Tinnitus: Tinnitus is associated with vancomycin ototoxicity at high doses or with prolonged therapy, not an immediate allergic reaction. It reflects potential auditory nerve or cochlear involvement rather than histamine-mediated responses.
Correct Answer is A
Explanation
A. Client report of uterine cramping: Oxytocin stimulates uterine contractions to control postpartum bleeding. Mild to moderate cramping is an expected and therapeutic effect of the medication, indicating the uterus is responding appropriately.
B. Boggy fundus 3 fingerbreadths above the umbilicus: A boggy, elevated fundus suggests ongoing uterine atony and uncontrolled bleeding, which is not an expected finding after oxytocin administration. This would require immediate reassessment and intervention.
C. Client report of burning with urination: Oxytocin does not affect the urinary tract directly. Dysuria is unrelated to oxytocin administration and is not an expected outcome.
D. Saturation of perineal pad in 15 min: Excessive bleeding despite oxytocin indicates insufficient uterine contraction or another complication. Effective oxytocin therapy should reduce vaginal bleeding, so rapid saturation of pads is an abnormal finding.
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