A nurse is assisting with the care of an adolescent.

Exhibits

Complete the following sentence by using the lists of options.

The adolescent is at risk for developing

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evidenced by

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Rationale for Correct Options:

• Heart rate. The heart rate has increased from 90/min on Day 1 to 132/min on Day 2. This significant elevation is concerning for worsening systemic inflammation, hypovolemia, or sepsis and requires immediate intervention.
• Respiratory status. The client initially had diminished breath sounds at the lung bases, but by Day 2, breath sounds are diminished throughout. This suggests worsening respiratory function, possibly due to acute respiratory distress syndrome (ARDS) or pleural effusion, both of which can complicate severe pancreatitis. Immediate assessment and intervention are necessary.
• Mental confusion. The client was alert and oriented on Day 1 but is now disoriented to person, place, and time on Day 2. This change in mental status can indicate worsening systemic inflammation, sepsis, hypoxia, or metabolic disturbances such as hypocalcemia. Immediate evaluation is needed.
• Blood pressure. While the client’s initial blood pressure was stable at 126/78 mm Hg, the current reading is not provided. If the client is experiencing hypotension, it could indicate worsening shock, requiring urgent intervention.
• Temperature. The client’s temperature increased from 37.2 °C (99 °F) on Day 1 to 38.9 °C (102 °F) on Day 2. This suggests a developing infection, such as infected pancreatic necrosis or sepsis, which requires immediate reporting and further evaluation.
• Cold, clammy skin. Cold, clammy skin is a sign of poor perfusion, which may indicate impending shock due to worsening sepsis or hypovolemia. This is an urgent finding requiring immediate attention.

Rationale for Incorrect Options:

• Urine output. The client’s urine output was documented as 60 mL/hr, which is within the normal range. There is no indication of oliguria or anuria that would require immediate reporting.
• Sodium level. The sodium level of 142 mEq/L is within the normal range and does not indicate a critical electrolyte imbalance requiring urgent intervention.
• Pain. The client’s pain has increased from 8/10 to 10/10 despite receiving morphine via a PCA pump. While pain management is crucial, worsening pain alone is not the most urgent concern compared to systemic complications like respiratory failure or hemodynamic instability.
• Serum amylase level. Although the serum amylase level is significantly elevated at 498 units/L, this is expected in acute pancreatitis and does not necessarily indicate an immediate life-threatening emergency. Trends in amylase and lipase levels are important for monitoring, but they do not require urgent reporting unless accompanied by other signs of deterioration.

A. "You should avoid exercising for the next 6 weeks." Exercise is encouraged after a total hip arthroplasty to promote circulation, prevent complications such as deep vein thrombosis, and strengthen the muscles supporting the hip joint. However, high-impact activities should be avoided until cleared by the healthcare provider.
B. "You should avoid putting a pillow between your legs when in bed." Placing a pillow between the legs, especially while sleeping, helps maintain proper hip alignment and prevents excessive internal rotation or adduction, reducing the risk of dislocation.
C. "You should avoid lying on your right side." Lying on the operative side is not necessarily contraindicated, but it should be done with caution and with proper support. Clients are usually advised to lie on their non-operative side with a pillow between their legs for alignment.
D. "You should avoid crossing your legs for 3 months." Crossing the legs can cause hip adduction and internal rotation, increasing the risk of dislocation of the prosthetic joint. Clients are typically instructed to avoid crossing their legs for at least 3 months or until cleared by their provider.