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A nurse is assisting with the care of an adolescent.

Exhibits

Select 1 condition and 1 finding to fill in each blank in the following sentence.

The adolescent is at risk for developing

as evidenced by

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}

The adolescent is at risk for developing compartment syndrome as evidenced by edema of toes.

Compartment syndrome is a serious condition where increased pressure within a muscle compartment can lead to decreased blood flow and tissue damage. The presence of moderate toe edema and fluctuating pain levels are concerning signs that may indicate the development of compartment syndrome, which requires prompt assessment and intervention.


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Related Questions

Correct Answer is C

Explanation

A. Insert an oral airway into the client's mouth.Inserting anything into the client’s mouth during a seizure is contraindicated due to the risk of oral injury, aspiration, or causing airway obstruction.

B. Lower the side rails of the bed when the seizure begins.Lowering the side rails is inappropriate and increases the risk of the client falling out of bed and sustaining an injury. Instead, the nurse should ensure padded side rails are in place or protect the client by cushioning their head and limbs if side rails are not padded.

C. Measure the duration of the seizure.It is critical to measure the duration of a seizure to provide accurate information to the healthcare team. The duration helps determine the severity of the seizure and the need for medical interventions, such as administering medications to stop prolonged seizures (status epilepticus).

D. Restrain the client's arms and legs to prevent injury.Restraint during a seizure is inappropriate and can cause musculoskeletal injuries. The nurse should allow the seizure to run its course while ensuring the client’s safety.

Correct Answer is A

Explanation

A. Correct. An incident report should be completed for any unintended event or situation that could have resulted or did result in harm to a patient. Administering the wrong dose of medication falls under this category.

B. Incorrect. The nursing care plan is a comprehensive outline of a patient's care needs and interventions and is not the appropriate place to document a medication error.

C. Incorrect. The provider's progress notes are meant to document the patient's condition, care, and progress, but they are not used to document medication errors.

D. Incorrect. The controlled substance inventory record is used to track the dispensing and administration of controlled substances, not to document medication errors.

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