Patient Data
The nurse addresses the client's pain and plans interventions to reduce further complications.
Choose the most likely options for the information missing from the statements by selecting from the lists of options provided.
The nurse monitors the client's
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Rationale for correct choices:
• Respirations: Morphine is an opioid analgesic that can depress the respiratory center in the brainstem, leading to slowed breathing and hypoventilation. Monitoring respirations after administration is critical to detect early signs of opioid-induced respiratory depression.
• Ice application to the shoulder: Applying ice reduces swelling, pain, and inflammation by causing vasoconstriction and limiting fluid accumulation at the injury site. For an acute humeral fracture with significant swelling and bruising, cold therapy is the appropriate intervention.
Rationale for incorrect choices:
• Nausea: While morphine can cause nausea and vomiting as side effects, they are not the most life-threatening concerns compared to respiratory depression. Monitoring nausea is appropriate but not the priority when evaluating opioid safety.
• Blood pressure: Morphine can cause hypotension, but this effect is less common and typically secondary to respiratory depression and vasodilation. Continuous monitoring of blood pressure is helpful, but respiratory monitoring takes priority in detecting opioid complications.
• Early active range of motion: Active movement of the injured arm is not recommended immediately after a displaced humeral fracture, as it can worsen displacement and interfere with healing. Immobilization and stabilization are required before introducing range-of-motion exercises.
• Heat application to the shoulder: Heat increases blood flow to tissues, which can worsen swelling and bleeding in the acute phase of injury. Applying heat too soon after a fracture increases the risk of complications rather than reducing them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B,B"},"F":{"answers":"B"},"G":{"answers":"A,B"}}
Explanation
• Chest pain: Blood clot embolism, especially pulmonary embolism, typically causes sudden chest pain due to obstruction of the pulmonary arteries. Fat embolism rarely causes chest pain as the primary symptom, though hypoxia may lead to discomfort. Chest pain is therefore more indicative of thrombotic embolism.
• Petechiae: Petechiae on the neck, upper chest, and conjunctiva are hallmark signs of fat embolism. They result from occlusion of dermal capillaries by fat globules and platelet aggregation. Blood clot embolism does not usually cause petechiae.
• Origin typically long bone fracture: Fat emboli commonly originate from fractures of long bones such as the femur, tibia, or pelvis. Trauma forces fat from the bone marrow into the bloodstream, creating emboli. Blood clot emboli generally do not arise from bone fractures.
• Altered mental status: Fat embolism can impair cerebral oxygenation, leading to confusion, lethargy, or agitation. This neurological involvement is a distinguishing feature of fat embolism. Blood clot embolism rarely affects mental status unless there is severe hypoxia.
• Dyspnea: Dyspnea occurs in both fat and blood clot embolism due to impaired oxygen exchange in the lungs. In fat embolism, hypoxia may develop gradually, while blood clot embolism often causes sudden shortness of breath. Both conditions require prompt respiratory support.
• Origin typically deep vein thrombosis: Blood clot emboli usually originate from deep veins in the legs or pelvis and travel to the lungs. Fat emboli are not associated with venous thrombi. Identifying the source helps differentiate between the two embolism types.
• Tachycardia: Tachycardia is a compensatory response to hypoxia or stress in both fat and blood clot embolism. It helps maintain oxygen delivery to vital organs. While nonspecific, its presence supports the need for urgent intervention in either condition.
Correct Answer is B
Explanation
A. Use electric heating pad when pain is at its worse: Heat can help relieve stiffness in arthritis, but during acute gout flares, applying heat may exacerbate inflammation. Cold therapy is generally recommended during severe joint pain episodes.
B. Increase fluid intake to 2000 mL per day: Adequate hydration helps prevent uric acid crystal formation, which can reduce the frequency and severity of gout attacks. Encouraging increased fluid intake is an important part of long-term management in clients with gouty arthritis.
C. Exercise daily for at least 30 minutes: While regular exercise supports weight loss and overall joint health, exercising during an acute flare can worsen pain and potentially injure the affected joint. Activity should be resumed gradually once inflammation subsides.
D. Eat high protein foods to achieve ideal body weight: High-protein diets, especially those rich in purines (e.g., red meat, organ meats), can exacerbate gout. Discharge teaching should focus on balanced nutrition with attention to foods that minimize uric acid levels.
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