A nurse is caring for a 7-year-old male client who sustained a traumatic injury to the left leg after being struck by a lawnmower while playing outside.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
TRALI is a life-threatening condition associated with blood transfusion. The client’s symptoms, including trauma and low hemoglobin, indicate the need for transfusion. TRALI can cause acute respiratory distress shortly after transfusion. Early intervention can improve outcomes. Recognizing the signs of TRALI is essential in such scenarios.
Rationale for actions
Administer oxygen: Oxygen supplementation can help manage hypoxemia associated with TRALI. It ensures adequate oxygenation during respiratory distress. Monitor for respiratory distress: Continuous assessment helps detect worsening symptoms. Early detection can prompt timely intervention. Rationale for parameters: Oxygen saturation: Monitoring SpO2 provides real-time information on the patient’s oxygenation status. It helps determine the effectiveness of oxygen therapy. Heart rate: Tachycardia can indicate worsening respiratory distress or hypoxemia. Monitoring heart rate is crucial for early detection of complications.
Rationale for incorrect conditions
Transfusion-associated circulatory overload (TACO): TACO involves fluid overload, leading to cardiac symptoms. However, this client’s presentation suggests acute lung injury, not fluid overload. Incorrect conditions (others): Abandonment: Not applicable as the client was brought to the hospital and received care. Physical abuse: No evidence of physical abuse in this case. Self-neglect: The client is a child, and the injury was accidental, not due to neglect. The parents brought him to the hospital promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Mixed berries are rich in antioxidants and nutrients, but they do not specifically provide the calcium and vitamin D necessary to support bone health in postmenopausal women, who are at increased risk for osteoporosis.
Choice B rationale
Low-fat yogurt is a good source of calcium and vitamin D, which are vital for maintaining bone density and preventing osteoporosis in postmenopausal women. These nutrients are crucial as estrogen levels drop, increasing the risk of bone loss.
Choice C rationale
Carrots are high in beta-carotene and fiber but do not significantly contribute to calcium and vitamin D intake. While beneficial for overall health, they are not the primary focus for bone health in postmenopausal women.
Choice D rationale
Beets offer various vitamins and minerals but lack substantial amounts of calcium and vitamin D. They are not emphasized for bone health in postmenopausal women, who need to prioritize nutrients that support bone density.
Correct Answer is D
Explanation
Choice A rationale
The client's healthcare power of attorney is important information but not the most urgent detail to report when there is a sudden change in the client's condition. Immediate clinical changes take priority.
Choice B rationale
The fall at home as the reason for admission provides background information but does not address the urgent change in the client's mental status. The primary focus should be on the sudden increase in confusion.
Choice C rationale
Currently prescribed medications are important to consider, especially if they could contribute to the client's confusion. However, the sudden change in mental status is more critical to report first.
Choice D rationale
Increasing confusion of the client is the most urgent information to report. It indicates a significant change in the client's condition that requires immediate assessment and intervention by the healthcare provider. Identifying and addressing the cause of this change is crucial to prevent further complications.
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