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. Remove the tape by pulling from the center of the dressing. Tape should be removed by pulling toward the wound rather than from the center to avoid skin trauma and unnecessary disruption to the healing tissue. Pulling from the center can increase discomfort and damage surrounding skin.
B. Clean the wound from the center to the outer edges. Cleaning from the center outward prevents the introduction of microorganisms from the surrounding skin into the wound, reducing the risk of further infection. This technique follows the principle of working from the cleanest area to the least clean.
C. Moisten the dressing before removal. A wet-to-dry dressing is meant to adhere to necrotic tissue and debris, which is then removed when the dry dressing is taken off. Moistening it before removal defeats this purpose by softening the dressing, reducing its effectiveness in debriding the wound.
D. Wear sterile gloves to remove the dressing. Clean gloves are appropriate for removing a contaminated dressing. Sterile gloves are necessary for applying the new dressing to maintain an aseptic environment. Using sterile gloves for removal is unnecessary and does not improve infection control.
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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