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 D
Explanation
A. Uncapped sharps are put in a puncture-resistant container: Proper disposal of sharps in a puncture-resistant container reduces the risk of needlestick injuries and infection. This is a safe practice and does not pose an infection risk to an immunocompromised client.
B. Dampened cloths are used for dusting the area: Using dampened cloths for dusting helps prevent airborne particles from spreading, reducing the risk of inhaling harmful pathogens. This method is considered appropriate for infection control.
C. Waste containers are lined with single bags: Using single-lined waste containers is a standard infection control practice that helps contain biohazardous waste properly. It does not pose a significant infection risk when handled correctly.
D. Soiled linens are placed on the floor: Placing soiled linens on the floor increases the risk of contaminating the environment with pathogens, which can be dangerous for an immunocompromised client. Linens should be placed in designated hampers immediately to prevent cross-contamination and the spread of infections.
Correct Answer is []
Explanation
Potential Condition:
Kawasaki disease: The child presents with prolonged fever, mucocutaneous changes (cracked lips, red tongue), extremity changes (edema, peeling skin), cervical lymphadenopathy, and elevated inflammatory markers (WBC, ESR, CRP, and platelets), all of which are consistent with Kawasaki disease.
Actions to Take
Administer IVIG: IVIG is the primary treatment to reduce inflammation and prevent coronary artery aneurysms.
Administer high-dose aspirin: Used in the acute phase to reduce inflammation and fever and in the subacute phase to prevent clot formation.
Parameters to Monitor
Heart rhythm: Kawasaki disease can cause myocarditis and coronary artery aneurysms, leading to arrhythmias.
Chest discomfort: A sign of coronary artery complications, including aneurysms or ischemia.
Rationale for Incorrect Diagnoses:
Bacterial endocarditis: Does not cause peeling skin or bright red tongue. Fever would be accompanied by murmurs and a history of heart defects.
Nephrotic syndrome: Characterized by severe proteinuria, edema, and hypoalbuminemia, which are absent here.
Acute post-streptococcal glomerulonephritis: Would present with recent strep infection, hematuria, hypertension, and periorbital edema, which are not mentioned.
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