Try Naxlex NCLEX-RN (Free-Trial)

The nurse is continuing to care for the child.

Exhibits

Complete the following sentence by using the lists of options.

The child is at highest risk for developing

as evidenced by the child's .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Rationale for Correct Choices:

  • Compartment Syndrome: Compartment syndrome is a limb-threatening condition that occurs when increased pressure within a muscle compartment impairs circulation and nerve function. The child has a nondisplaced fracture of both the radius and ulna, along with edema, ecchymosis, and fingers that are cool to touch, all of which are early signs of compromised perfusion.
  • Tingling Sensation: Tingling (paresthesia) is an early neurological sign of impaired sensory function often seen in the early stages of compartment syndrome. This child verbalizes a mild tingling in the fingers, which indicates nerve compression due to increased pressure within the forearm compartments.

Rationale for Incorrect Choices

  • Paresthesia: Tingling is the hallmark symptom of paresthesia, but paresthesia is a symptom, not a disease process. The nurse must determine the underlying cause of the altered sensation, which in this situation is likely compartment syndrome.
  • Deep Vein Thrombosis (DVT): DVT typically presents with unilateral leg swelling, warmth, pain, and sometimes redness—not forearm injury symptoms. The child has a forearm fracture and bruises on the lower extremities in different healing stages, but there's no localized swelling, erythema, or immobility in the legs to support a DVT diagnosis.
  • Pain Level: A pain score of 4 out of 10 is not severe enough to support compartment syndrome or any acute vascular crisis alone. Pain that is out of proportion to the injury and unrelieved by medication would raise concern.
  • Mobility: The child is ambulatory and able to move their fingers and limbs, which reduces the likelihood of venous stasis a major risk factor for DVT. In the absence of prolonged immobility or systemic hypercoagulability, there is minimal reason to suspect a thrombotic event based on mobility alone.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B"},"D":{"answers":"A,B,C"}}

Explanation

Rationale:

  • Sensation: Tingling indicates possible nerve irritation or mild neurovascular compromise. This is often seen in fractures when swelling or bone displacement compresses nerves near the injury site, especially in long bones like the radius.
  • Ecchymosis: Bruising results from soft tissue bleeding and is common in all three conditions due to trauma to blood vessels. Ligament tears (sprain), bone injury (fracture), and capsule damage (dislocation) can all lead to ecchymosis.
  • Pain level: Moderate pain, such as a 4/10 rating, is consistent with both sprains and fractures. Sprains stretch or tear ligaments, while fractures disrupt bone structure. Dislocations usually present with severe, sharp pain that impairs joint movement entirely.
  • Edema: Swelling is a nonspecific but common response to tissue injury. It occurs with ligament strain (sprain), bone disruption (fracture), and joint trauma (dislocation), all of which lead to localized inflammation and fluid accumulation.

Correct Answer is B

Explanation

Rationale:

A. "This helps to keep you hydrated.": Flushing an intermittent infusion device does not hydrate the client, as the small amount of saline used is not intended for fluid replacement. Hydration is achieved through continuous or scheduled fluid administration, not flushes.

B. "This clears blood from the tubing and the catheter.": Flushing helps maintain catheter patency by preventing blood from clotting inside the lumen. It ensures the device remains functional and ready for medication administration when needed.

C. "This makes sure it stays sterile.": Flushing does not sterilize the device. Sterility is maintained through proper handling and use of aseptic technique. The purpose of flushing is mechanical, not antimicrobial.

D. "This prevents leakage of fluid and medication.": While flushing may help confirm that the device is intact, the primary reason is not to prevent leakage but to maintain patency and ensure the catheter is free of occlusions.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register