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 A
Explanation
A. Case manager. A case manager assists clients in accessing community resources, including financial assistance programs such as WIC (Women, Infants, and Children) and other social services that provide formula for infants. This referral ensures the client receives the necessary support to meet her baby's nutritional needs.
B. Primary care provider. A primary care provider focuses on the client’s medical care rather than financial or social concerns. While they may provide guidance on infant nutrition, they are not the best resource for addressing the client’s financial difficulties in obtaining formula.
C. Nutritionist. A nutritionist provides dietary guidance but does not handle financial assistance programs. They may educate the client on proper infant feeding, but they cannot directly assist with obtaining formula for a client who cannot afford it.
D. Pediatric nurse practitioner. A pediatric nurse practitioner specializes in infant health but does not typically manage financial concerns. They may assess the baby’s growth and nutritional needs but would refer the client to a case manager or social services for formula assistance.
Correct Answer is B
Explanation
A. Administer granulocyte colony-stimulating factor. This medication stimulates neutrophil production in clients with severe neutropenia, such as those undergoing chemotherapy. While HIV can cause neutropenia, routine administration is not necessary unless the infant has recurrent infections and significantly low neutrophil counts.
B. Monitor the infant's lymphocyte count. CD4+ T-cell levels are key indicators of immune function in infants with HIV. Since HIV targets these cells, regular monitoring helps assess disease progression and the effectiveness of antiretroviral therapy, guiding treatment adjustments when needed.
C. Educate the infant's guardians about exchange transfusions. Exchange transfusions are used for conditions like severe neonatal hyperbilirubinemia or sickle cell disease, not HIV. Managing HIV in infants focuses on early antiretroviral therapy, routine lab monitoring, and infection prevention.
D. Initiate droplet precautions. Standard precautions, such as hand hygiene and appropriate use of personal protective equipment, are sufficient for infection control. HIV is not transmitted through respiratory droplets but through direct contact with infected blood, breast milk, or other bodily fluids.
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