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. "You can apply counterpressure to your back with each position change." Counterpressure is commonly used for pain relief during labor, particularly for back labor caused by fetal positioning. It is not a typical nonpharmacological intervention for post-cesarean pain management.
B. "You should change positions as little as possible." Frequent position changes help promote circulation, prevent complications such as deep vein thrombosis, and reduce stiffness. Encouraging mobility with proper pain management is essential for recovery after a cesarean birth.
C. "You should use patterned-paced breathing when changing positions." Patterned-paced breathing is a technique used during labor for pain management and relaxation. While controlled breathing may help with general discomfort, it is not the most effective strategy for post-cesarean pain during movement.
D. "You can splint the incision with a pillow when changing positions." Holding a pillow against the incision site provides support, reduces strain on the abdominal muscles, and minimizes pain when moving, coughing, or laughing. This is a well-established method for post-cesarean pain relief.
Correct Answer is D
Explanation
A. "You should only drink 2 cups of coffee per day." While limiting coffee intake can be beneficial for some individuals with GERD, the recommendation should focus on overall caffeine intake rather than a specific amount. Caffeine can relax the lower esophageal sphincter and exacerbate symptoms, so some individuals may need to eliminate it entirely.
B. "You should eat three large meals and two snacks per day." Eating large meals can increase intra-abdominal pressure and exacerbate GERD symptoms. Instead, clients should be encouraged to eat smaller, more frequent meals throughout the day to help minimize reflux.
C. "You should lay down for 1 hour following a meal." Laying down after eating can increase the likelihood of reflux and heartburn. Clients should be advised to remain upright for at least 2 to 3 hours after meals to help prevent symptoms.
D. "You should elevate the head of the bed while sleeping." Elevating the head of the bed is a recommended practice for clients with GERD. This position can help prevent nighttime reflux by allowing gravity to keep stomach acid from rising into the esophagus, thereby reducing symptoms and improving sleep quality.
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