Exhibits
Specify which potential 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 response.
The Correct Answer is []
- The client is most likely experiencing compartment syndrome, which is a condition where increased pressure within a closed space compromises blood flow and tissue perfusion. Compartment syndrome can occur after a fracture, especially if a cast or splint is applied too tightly. Some of the signs and symptoms of compartment syndrome are severe pain, paresthesia, pallor, and pulselessness.
- Two actions the nurse should take to address compartment syndrome are:
- Elevate the extremity above the level of the heart to reduce swelling and improve venous return.
- Remove the cast or loosen the dressing to relieve the pressure and restore blood flow. This may require notifying the physician or obtaining an order for bivalving or cutting the cast.
- Two parameters the nurse should monitor to assess the client’s condition are:
- Capillary refill of the affected fingers, which should be less than 3 seconds. A prolonged capillary refill indicates poor perfusion and tissue ischemia.
- Blood pressure of the client, which should be maintained within normal limits. Hypotension can worsen the perfusion deficit and lead to tissue necrosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Fasting blood sugar of 200 mg/dL (11.1 mmol/L) indicates hyperglycemia, which is a high level of glucose in the blood. It can be caused by diabetes mellitus, stress, infection, or medication. Hyperglycemia can cause symptoms such as thirst, hunger, frequent urination, fatigue, and blurred vision. However, it does not affect the safety or accuracy of MRI with contrast.
Choice B reason: Glycosylated hemoglobin A1c of 8% indicates poor glycemic control over the past three months. It can be caused by diabetes mellitus, chronic kidney disease, or hemoglobinopathy. Glycosylated hemoglobin A1c reflects the average blood glucose level over the lifespan of red blood cells, which is about 120 days. However, it does not affect the safety or accuracy of MRI with contrast.
Choice C reason: Blood urea nitrogen of 22 mg/dL (7.9 mmol/L) indicates mild azotemia, which is a high level of nitrogenous waste products in the blood. It can be caused by dehydration, high protein intake, gastrointestinal bleeding, or kidney impairment. Azotemia can cause symptoms such as nausea, vomiting, confusion, and lethargy. However, it does not affect the safety or accuracy of MRI with contrast.
Choice D reason: Serum creatinine of 1.9 mg/dL (169 umol/L) indicates moderate renal insufficiency, which is a reduced ability of the kidneys to filter and excrete waste products and fluids from the body. It can be caused by diabetes mellitus, hypertension, glomerulonephritis, or nephrotoxic drugs. Renal insufficiency can cause symptoms such as edema, anemia, electrolyte imbalance, and acidosis. It can also increase the risk of contrast-induced nephropathy, which is a sudden deterioration of kidney function after exposure to contrast media used for imaging studies such as MRI. Contrast-induced nephropathy can lead to acute kidney injury, dialysis requirement, or even death. Therefore, serum creatinine should be reported to the healthcare provider before MRI with contrast to assess the risk and benefit of the procedure and to take preventive measures such as hydration, medication adjustment, or alternative imaging modalities.
Correct Answer is D
Explanation
Choice A reason: Jogging or running are not excellent aerobic exercises for an older adult client with osteoarthritis. These activities can put a lot of stress and impact on the joints, especially the knees, hips, and ankles, which can worsen the pain and inflammation of osteoarthritis. The nurse should advise the client to avoid high-impact exercises that can damage the cartilage and bones.
Choice B reason: Tennis or racquetball are not ideal exercises for an older adult client with osteoarthritis. These activities involve sudden movements, twists, and turns that can strain the joints, especially the elbows, wrists, and shoulders, which can aggravate the symptoms of osteoarthritis. The nurse should advise the client to avoid exercises that can cause joint instability and injury.
Choice C reason: Limiting the exercise to just the daily activities is not a good advice for an older adult client with osteoarthritis. Exercise is important for maintaining joint health, mobility, and function, as well as preventing muscle loss, obesity, and cardiovascular diseases. The nurse should encourage the client to engage in regular moderate exercise that can improve the quality of life and reduce the complications of osteoarthritis.
Choice D reason: Swimming is an excellent exercise for an older adult client with osteoarthritis. Swimming is a low-impact aerobic exercise that can strengthen the muscles, improve the cardiovascular fitness, and enhance the flexibility of the joints without putting too much pressure or stress on them. Swimming can also reduce the pain and stiffness of osteoarthritis by providing a soothing and relaxing effect on the body. The nurse should recommend swimming as a safe and effective exercise for the client.
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