A nurse is caring for 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":"C","dropdown-group-2":"C"}
Rationale for correct choices
• Compartment syndrome: The adolescent demonstrates escalating pain despite repeated opioid administration, along with moderate edema, delayed capillary refill, and numbness/tingling in the affected limb. These signs indicate increased pressure within the casted compartment, which can compromise circulation and nerve function.
• Increasing capillary refill times: Capillary refill has lengthened from 3 to 4 seconds, suggesting impaired peripheral perfusion in the affected extremity. This change indicates vascular compromise and aligns with the pathophysiology of compartment syndrome. Monitoring these subtle vascular changes helps identify early ischemia before permanent damage occurs.
Rationale for incorrect choices
• Pneumonia: Shallow respirations and a slightly increased respiratory rate are present but are mild and likely related to pain or anxiety. Breath sounds remain clear, and oxygen saturation is slightly decreased but not critically low. There is no productive cough, fever spikes, or infection in the lungs, making pneumonia less likely.
• Infection: While the adolescent’s temperature has risen slightly, there is no redness, drainage, or local signs at the surgical site. White blood cell counts are not provided, and systemic signs of infection are minimal. The mild fever could be due to stress or inflammation from surgery rather than infection. Current symptoms points toward neurovascular compromise rather than infection.
• Shallow respirations: Although respirations are shallow at times, this finding alone is more consistent with pain or guarding from the femur injury than with a systemic complication. Respiratory assessment does not demonstrate adventitious sounds or significant hypoxia. Shallow breathing is not the primary indicator of compartment syndrome.
• Increasing respiratory rate: The rise in respiratory rate is minor and likely a response to pain, stress, or mild hypoxia, not the early sign of compartment syndrome. Tachypnea without other systemic signs does not reliably indicate limb vascular compromise. While important to monitor, it is not specific to the identified risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Instruct visitors to put on a gown and gloves before entering the client's room: Contact precautions require the use of personal protective equipment, including gowns and gloves, to prevent transmission of infectious agents via direct or indirect contact. Visitors and healthcare personnel should don these items before entering the room.
B. Place a box of surgical masks outside the client's room: Masks are used for droplet or airborne precautions, not routine contact precautions. Providing masks outside the room is not necessary unless droplet or airborne infection is suspected.
C. Assign the client to a negative pressure room: Negative pressure rooms are required for airborne precautions, not contact precautions. Contact precautions focus on hand hygiene and barrier protection rather than specialized airflow.
D. Ensure all gloves in the client's room are nonlatex: While glove selection may depend on allergy considerations, using nonlatex gloves is not a requirement specifically for contact precautions. Standard or nitrile gloves are acceptable unless a latex allergy is present.
Correct Answer is ["A","C"]
Explanation
A. Allow extra time for the client to perform tasks: Clients with vision loss may require additional time to navigate their environment and complete activities safely. Providing extra time reduces stress, supports independence, and promotes a sense of autonomy while performing daily tasks.
B. Touch the client gently to announce presence: The nurse should announce presence verbally first. Touching without warning may startle the client.
C. Keep objects in the client's room in the same place: Maintaining a consistent arrangement of personal items prevents confusion and reduces the risk of falls or accidents. Predictable placement allows the client to perform tasks safely and maintain independence.
D. Approach the client from the side: Approaching from the side is not recommended because it may startle the client. Best practice is to approach from the front while using verbal cues to announce your presence and provide orientation.
E. Ensure there is high-wattage lighting in the client's room: High-intensity lighting may cause glare and discomfort for clients with vision loss, especially those with conditions like macular degeneration. Adequate but non-glare lighting is preferable to support safe mobility.
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