A nurse is caring for a client in an orthopedic unit.
Drag words from the choices below to fill in each blank in the following sentence.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}
- Deep vein syndrome: This is not a recognized condition. The intended term may have been deep vein thrombosis (DVT), which is a valid orthopedic complication, but the clinical findings in this scenario point more urgently toward compartment syndrome and infection.
- Osteomyelitis: The client has an open fracture with drainage from the splint, a significantly elevated WBC count (28,000/mm³), and a high fever (38.9°C / 102°F). These findings suggest the development of a bone infection (osteomyelitis), especially in the context of recent surgery and internal fixation.
- Fat embolism syndrome: While fat embolism is a risk with long bone fractures, this client is not displaying key hallmark signs such as respiratory distress, petechiae, or altered mental status. The findings are more consistent with infection and circulatory compromise.
- Compartment syndrome: The client has classic signs including cool foot, numbness, inability to move toes, absent pulses, delayed capillary refill, and increased pain. These are hallmark signs of neurovascular compromise from compartment syndrome, a surgical emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "You have already consented to this treatment, so you must continue." This response disregards the client’s autonomy. Clients have the right to withdraw consent and stop treatment at any time, even after initially agreeing to it.
B. "I will let your doctor know that you want to discontinue treatment." This response respects the client’s right to make decisions about their care and ensures that the healthcare team is informed to support the client appropriately. It demonstrates advocacy and ethical practice.
C. "You should discuss this with your family and see if they agree." While family input can be helpful, the final decision rests with the client, not their family. This response may undermine the client’s autonomy.
D. "I know this treatment is difficult for you, but you will feel better." This is a minimizing statement that may come across as dismissive. It does not acknowledge the client’s feelings or support their decision-making process.
Correct Answer is B
Explanation
A. "A cesarean birth is the only way to prevent transmission." Cesarean delivery is considered if active lesions or prodromal symptoms are present at the time of labor. However, it is not automatically required for all clients with a history of herpes.
B. "If you notice genital tingling be sure to notify your provider." Genital tingling or burning can be a prodromal sign of an impending herpes outbreak. Early reporting allows for appropriate evaluation and potential antiviral treatment to reduce the risk of transmission to the newborn.
C. "Hydrotherapy during labor can help reduce transmission." Hydrotherapy has no effect on herpes virus transmission and is not used for this purpose. Preventing neonatal herpes depends on careful monitoring and antiviral management.
D. "The provider will perform weekly visual inspections for lesions." Routine weekly inspections are not standard unless symptoms suggest an outbreak. Clients are generally monitored and evaluated for lesions closer to labor or if symptoms arise.
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