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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.


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Related Questions

Correct Answer is B

Explanation

Rationale:

A. Obtain a 12-lead ECG for the client: An ECG is important for diagnosing myocardial ischemia or infarction, but it is not the immediate first step. The priority is to stop activity and reduce myocardial oxygen demand before further diagnostics.

B. Have the client stop walking and sit down: Angina is often triggered by physical exertion. Stopping activity and sitting down reduces oxygen demand on the heart, alleviates symptoms, and prevents further ischemia. This is the most immediate and essential first action.

C. Administer sublingual nitroglycerin to the client: Nitroglycerin helps relieve anginal pain by dilating coronary arteries, but it should be given after the client has stopped activity and rested. Administering it while the client is still active may not be effective or safe.

D. Measure the client's vital signs: While vital signs are important for assessing the client’s current status, the priority is to stop exertion, which is likely contributing to myocardial oxygen imbalance. Assessment follows immediate symptom relief measures.

Correct Answer is C

Explanation

Rationale:

A. Select a vein on the back of the hand: Veins on the dorsum of the hand are often more fragile and prone to infiltration or rupture in older adults. Using a more proximal site, such as the forearm, is generally safer and more stable for IV therapy.

B. Clean the site using vigorous friction: Older adults often have thinner, more delicate skin that can tear easily. While proper antiseptic technique is important, vigorous friction can cause skin trauma and should be avoided during site preparation.

C. Use a 22-gauge catheter for insertion: A 22-gauge catheter is appropriate for older adults because it minimizes vein trauma while still allowing for adequate flow rates. This size is effective for most fluids and medications while reducing the risk of vessel damage.

D. Apply a tourniquet firmly above the insertion site: Applying a tourniquet too tightly can injure fragile veins or cause them to collapse. In older adults, using minimal pressure or alternative vein-dilation methods like warm compresses is often safer.

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