A nurse is assisting with the care of an adolescent.
Select 1 condition and 1 finding to fill in each blank in the following sentence.
The adolescent is at risk for developing
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choiceB. Fever.
Choice A rationale:
Peeling of the hands and feet is not a typical manifestation of pertussis.This symptom is more commonly associated with conditions like Kawasaki disease.
Choice B rationale:
Fever is a common symptom in the early stages of pertussis, along with a mild cough and runny nose.
Choice C rationale:
A beefy, red tongue is not associated with pertussis.This symptom is more characteristic of scarlet fever.
Choice D rationale:
Facial erythema is not a typical symptom of pertussis.Pertussis primarily affects the respiratory system, causing severe coughing fits.
Correct Answer is B
Explanation
A. Incorrect. Instructing the client's family about the purpose of mitten restraints requires nursing judgment and explanation. It is beyond the scope of an assistive personnel's role.
B. Correct. Assisting the client with a range of motion exercises of the hands is a task that can be safely delegated to assistive personnel. It is a routine activity and does not require advanced assessment.
C. Incorrect. Evaluating the need for the client to remain in restraints requires nursing assessment and decision-making.
D. Incorrect. Determining the circulation status of the extremities requires nursing assessment skills and clinical judgment. It is not appropriate to delegate this task to assistive personnel.
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