Exhibits

The parents are at the bedside and state that each parent thought the other parent was watching the child. They are not sure how long he was in the pool or how he might have fallen in. The temperature of the pool was cool as the temperature outside was about 64 °F (17.8 °C).

Placed a cervical collar with the assistance of the physician. The child's pulse is 121 beats/minute, the airway is patent, and there are no signs of any bleeding.

Review H and P, nurse's note, laboratory results, orders, and imaging studies. What complications should the nurse monitor for in the next 6 to 8 hours? Select all that apply.

Cerebral edema

Acute asphyxia

Hypertension

Respiratory distress

Hyperthermia

Subdural hemorrhage

Answer and Explanation

Correct Answer : A,B,D,F

A)   Cerebral edema: Brain injury or trauma can lead to swelling and increased intracranial pressure.
B)   Correct- Near- drowning causes acute asphyxia because it prevents the person from breathing in oxygen and exhaling carbon dioxide. Asphyxia is a condition where the body is deprived of oxygen, which can lead to loss of consciousness, brain injury, or death.
C)   Incorrect- Hypertension is not a common complication following near-drowning. The focus should be on potential brain injuries and respiratory distress.
D)   Correct- Near-drowning can lead to aspiration of water or other substances, which can result in respiratory distress.
E)   Incorrect- hyperthermia is not likely to occur in this case because the child was exposed to cold water.
F)   Correct- Head trauma can lead to bleeding within the brain, such as a subdural hemorrhage.

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Correct Answer is C

Explanation

Orlistat is a weight-control medication that works by inhibiting the absorption of dietary

fats in the intestines. It can also interfere with the absorption of fat-soluble vitamins (such as vitamins A, D, E, and K) and beta-carotene. Therefore, it is important for the client to take a multivitamin supplement to ensure an adequate intake of these essential nutrients.

However, it is recommended to take the multivitamin and orlistat at least two hours apart. This is because orlistat can potentially interfere with the absorption of the

fat-soluble vitamins in the multivitamin if taken simultaneously. By spacing them apart, the client can optimize the absorption of both the medication and the multivitamin.

Multivitamins are not contraindicated during treatment with orlistat. In fact, they are often recommended to compensate for potential nutrient deficiencies.

While orlistat may contain some vitamins and minerals, it does not provide all the recommended daily amounts. Therefore, additional supplementation may be necessary. While following a well-balanced diet is indeed important for good nutrition, it does not address the need for specific nutrient supplementation when taking orlistat. Both a balanced diet and appropriate vitamin supplementation can be beneficial in this situation.

A. Sloughing tissue around wound edges. B. Change in the quality of the peripheral pulses. C. Weeping serosanguineous fluid from wounds. D. Loss of sensation to the left lower extremity. E. Complaint of increased pain and pressure.

Correct Answer is ["B","D","E"]

Explanation

These findings suggest potential complications and compromise to the client's circulation and nerve function, which require immediate attention.

Changes in the quality of peripheral pulses indicate alterations in blood flow and may suggest vascular compromise or decreased perfusion to the affected areas. This finding requires immediate intervention to prevent further damage and ensure adequate blood supply to the extremities.

Loss of sensation to the left lower extremity can be indicative of nerve injury or impaired peripheral nerve function. It is important to assess for nerve damage and address it promptly to prevent complications and maximize the client's recovery.

Complaints of increased pain and pressure are concerning because they may indicate the development of compartment syndrome, a serious complication in which pressure within the muscles and tissues builds up to dangerous levels. Prompt intervention is necessary to relieve the pressure and prevent tissue damage.

While sloughing tissue around wound edges and weeping serosanguineous fluid from wounds are important assessment findings in the context of burn care, they do not require immediate intervention compared to the findings mentioned above. These findings should still be addressed and managed appropriately, but they are not considered immediate emergencies.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has received a prescription for orlistat for weight and nutrition management. In addition to the medication, the client plans to take a multivitamin. Which teaching should the nurse provide?

Correct Answer is C

Explanation

When caring for a client with full-thickness burns to both lower extremities, which assessment finding(s) warrant immediate intervention by the nurse? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer?

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having sex with multiple partners. Which response should the nurse provide

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In which, order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first, and least priority last or at the bottom.)

When assessing a newborn girl with salt-wasting congenital adrenal hyperplasia due to 21 hydroxylase deficiency, the nurse notes that the infant has an enlarged clitoris. Which intervention should the nurse implement?