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":"A","dropdown-group-2":"C"}
Rationale for Correct Options:
Compartment syndrome is a serious complication that can occur after a fracture, particularly of a long bone like the femur. It results from increased pressure within a muscle compartment, leading to decreased blood flow and potential tissue damage.
Edema of the toes suggests swelling, which may indicate increasing pressure within the affected limb. The adolescent is already reporting significant pain (7/10) and has required repeated doses of IV morphine, which may not be sufficient to relieve compartment syndrome pain (a key warning sign). If left untreated, compartment syndrome can cause nerve and muscle damage, ischemia, and even permanent disability.
Rationale for Incorrect Options:
Deep Vein Thrombosis (DVT): DVT is a risk with immobilization, but it usually presents with unilateral swelling, warmth, and pain in the affected limb, not just toe edema.
Fat Embolism Syndrome: This occurs due to fat globules entering circulation after a long bone fracture. Symptoms include respiratory distress, mental status changes, and petechiae, which are not present here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Believes that his brother's death will be reversible. This response is more typical of preschool-aged children (ages 3 to 5), who often perceive death as temporary or reversible, similar to sleep or separation. School-age children, however, begin to understand the finality of death, though they may still struggle with its implications.
B. Believes his bad behavior is causing his brother's death. School-age children (ages 6 to 12) often engage in magical thinking and may believe that their actions, thoughts, or behaviors are responsible for events, including illness and death. They may feel guilt and self-blame, thinking that past misbehavior contributed to their sibling's condition. Providing reassurance and education about the medical causes of the illness can help alleviate these feelings.
C. Alienates himself from his peers. While social withdrawal can occur in grieving children, school-age children typically seek peer support and may use friendships as a coping mechanism. Alienation is more commonly seen in adolescents, who might isolate themselves due to difficulty expressing emotions or fear of burdening others.
D. Regresses to an earlier developmental level. Regression, such as bedwetting, clinging behavior, or baby talk, is more commonly seen in younger children, particularly toddlers and preschoolers, when they experience stress or grief. School-age children are more likely to express distress through guilt, sadness, or behavioral changes rather than regression.
Correct Answer is A
Explanation
A. "I will stop what I am doing and lie down." Stopping activity and resting helps reduce myocardial oxygen demand, which can relieve stable angina. Lying down also minimizes strain on the heart and decreases the risk of injury if the client becomes lightheaded.
B. "I will call the provider after taking one dose of nitroglycerin." Clients with stable angina should take one dose of sublingual nitroglycerin and wait five minutes. If pain persists after three doses taken five minutes apart, emergency medical services should be contacted instead of waiting to call the provider.
C. "I will hold my breath and bear down." The Valsalva maneuver can increase vagal tone, leading to bradycardia and decreased cardiac output, which may worsen angina rather than relieve it. This is not an appropriate response to chest pain.
D. "I will take two 325 milligram aspirin tablets at the same time." While aspirin is beneficial for preventing platelet aggregation, the usual recommended dose for acute chest pain is a single 160–325 mg tablet chewed immediately. Taking two full-dose aspirin tablets is unnecessary and may increase the risk of bleeding.
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