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","B","E"]
Explanation
A. Wear a lead apron when providing care: Lead aprons help protect the nurse from radiation exposure when providing close care to a client with a sealed radiation implant. This is a standard safety precaution in managing patients receiving internal radiation therapy.
B. Close the door to the client's room: Keeping the door closed limits unnecessary exposure to radiation for other clients and staff in the unit. It also helps maintain a controlled environment for infection and radiation safety.
C. Place the client in a semi-private room: Clients with sealed radiation implants should be placed in a private room to minimize radiation exposure to other patients and staff. Semi-private rooms increase the risk of unnecessary exposure and are not recommended.
D. Limit visitors to 30 min per day: Visitor time is restricted to reduce radiation exposure, but current guidelines typically recommend limiting exposure to 30 minutes per visit rather than per day. Overly strict cumulative limits are less emphasized than per-visit exposure.
E. Instruct visitors who are pregnant to remain 3 feet from the client: Pregnant visitors are at risk of radiation-related fetal harm, so maintaining a safe distance helps minimize exposure. Educating visitors about safety and distance is an essential protective measure.
Correct Answer is C
Explanation
A. Remove the skin markings following radiation: Skin markings should not be removed during radiation therapy, as they are necessary for accurate targeting of radiation. Removing them can interfere with treatment accuracy and is not recommended.
B. Apply lotions liberally to the skin: While moisturizing can help with dryness, during radiation therapy, the nurse should recommend only mild, non-irritating, fragrance-free lotions approved by the radiation team. Applying products liberally or unapproved lotions can interfere with radiation dosing.
C. Wear protective clothing when outside: Radiation can make the skin more sensitive to sunlight. Wearing protective clothing and using sun protection helps prevent additional irritation, burns, or damage to already vulnerable skin. This is an appropriate measure to manage skin integrity.
D. Cleanse skin with an antibacterial cleanser: Antibacterial or harsh cleansers can irritate the sensitive skin of a child undergoing radiation therapy. Gentle, mild, fragrance-free soap and lukewarm water are preferred to maintain skin integrity without causing further damage.
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